1. Thanks to Migrant Clinics Network, Institute for Health Care Improvement, Marc Williams- Intermountain Healthcare & Mike Hindmarsh MacColl Institute for Health Care Innovation Institute For Healthcare Improvement Paul Bray, MA, LMFT Assistant Research Professor, Dept. of Family Medicine, ECU Work e-mail pbray@pcmh.compbray@pcmh.com Need for Quality, Introduction to Quality Improvement and PCMH

2. Why are we discussing improving quality in health care? It is the center of discussion with health care reform: All reform emphasis quality Its on your certification exams: Specialty board certification & JCAHO (Joint Commission on Accreditation of Health Care Organizations) accreditation It can increase your pay: Incentive pay, managed care pay, patient centered medical home and Pay for performance It can keep you competitive: Learn about quality improvement because it is a world wide movement Most important, for your patients: Learn about the methods to help your patients

3. The IOM Quality Report- To Err Is Human: Building a Safer Health System Do we have a quality Problem in US health care? Consensus: We do not have a problem we have a CRISIS!

4. To Err is Human Medical Injuries IOM November 1999 Report 44,000-98,000 deaths per year through medical errors More people die from medical errors than from breast cancer or AIDS or motor vehicle accidents 100,000 deaths per year from procedures/surgery complications, exceeding motor vchicle deaths Direct health care costs $9-15 billion/year Its a conservative estimate!!

5. March 1, 2001 Between the health care we have and the care we could have lies not just a gap, but a chasm. The IOM Quality Report- Update 2001

6. How Good Are We? Only 50% of Americans receive recommended preventive care Patients with acute illness 70% received recommended treatments 30% received contraindicated treatments Patients with chronic illness 60% received recommended treatments 20% received contraindicated treatments Schuster et al. How good is the quality of healthcare in the United States? Milbank Quarterly 76:517-63, 1998

7. The toll on patients is high: US Data Source: Elizabeth McGlynn, et al. The Quality of Health Care Delivered to Adults in the US. NEJM 2003; 348:2635-45 CONDITION SHORTFALL IN CARE AVOIDABLE TOLL Diabetes Hypertension Heart attack Pneumonia Colorectal cancer Average blood sugar not measured for 24% 29,000 kidney failures - 2,600 blind Less than 65% received indicated care - 68,000 deaths 39% to 55% didn't receive needed medications - 37,000 deaths 36% of elderly didn't receive vaccine - 10,000 deaths 62% not screened - 9,600 deaths

8. Source: World Banks World Development Indicators, UC Atlas

9. "T HIS WEEK I CONVEYED TO C ONGRESS MY BELIEF THAT ANY HEALTH CARE REFORM MUST BE BUILT AROUND FUNDAMENTAL REFORMS THAT LOWER COSTS, IMPROVE QUALITY AND COVERAGE, AND ALSO P ROTECT C ONSUMER CHOICE," B ARACK O BAMA J UNE 6, 2009

11. The IOM Quality report: A New Health System for the 21st Century Institute of Medicine The current care systems cannot do the job. Trying harder will not work. Changing care systems will. http://www.iom.edu/CMS/8089.aspx

13. Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Chronic Care Model or Planned Care Model

14. The patient centered medical home is a model for care provided by physicians practices that seeks to strengthen the physician patient relationship by replacing episodic care based on illnesses and patient complaints with coordinated care and a long term healing relationship. Primary Care as the key to Quality: Patient-Centered Medical Home (PCMH) Reimbursement is central to PCMH and Quality Improvement Reform Proposal: fees + PCMH pay-per-patient + performance from system of quality

15. 1. Team based care 2. Whole person orientation 3. Care coordination 4. Enhanced access 5. Systems for quality 6. Systems for safety Characteristics of PCMH (National Center for Quality Assurance)

16. 24/7 Access and Communication Patient Tracking and Registry Functions Care Management from a nurse or other non-physician Patient Self Management Support Electronic Prescribing Test Tracking Referral Tracking Performance Reporting and Improvement, team reviews results Advanced Electronic Communications How do we know a clinic is a PCMH

18. How do we have systems of quality? (One of the 6 requirements of a PCMH) Set a goal (if you do not have a target, that is what you will hit) Form a team Take Small steps Measure your progress- collect data

19. CORE STEPS IN CONTINUOUS IMPROVEMENT (i.e. diabetes) Define a clear aim (reduced morbidity from diabetes) Identify and define measures of success. (>40% < 7 A1c) Form a team that has knowledge of the system needing improvement (physician, dia. Ed, scheduler) Brainstorm potential change strategies for producing improvement. (add 20 min ed visit to >7) Plan, collect, and use data for facilitating effective decision making. (measure A1c for ed vs. non ed) Apply the scientific method to test and refine changes (id best curriculum & self-management)

20. What is the PDSA Cycle? Act What changes are to be made? Next cycle? maintain modify add to the plan Plan Objective Questions and predictions (why) Plan to carry out the cycle (who, what, where, when) Study Complete the analysis of the data Compare data to predictions Summarize what was learned Do Carry out the plan Document problems and unexpected observations Begin analysis of the data

21. How do we get there? 1. Define a Problem 2. Set a Goal 3. Form a Team 4. Plan for a change using small scale steps 5. Do the change 6. Study- collect data & analyze change/outcome 7. Act – correct, repeat, spread, install

22. Achievements In the first Diabetes Collaborative applying the CCM; enrolling 16,000 people with diabetes. The national shared performance measure of two Hemoglobin A1c (HbA1c) tests done within a year increased by almost 300%. Diabetes pilot patients had significantly reduced CVD risk (pilot>control), resulting in a reduced risk of 1 cardiovascular disease event for every 48 patients exposed (RAND Corp. Study www.improvingchroniccare.org).

23. Reading List for Residence First QI Application Session ECU Getting Started Powerpoint Presentation CQI Family Medicine CQI Introduction Mike Hindmarsh chronic care model intro IHI Improvement Methods Intro Web Site http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/ Tools: Cause-effect Fish-bone exercise http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Tools/Cause+an d+Effect+Diagram.htm Tools: Pareto Diagram Exercise http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Tools/Pareto+Dia gram.htm

24. Resources http://www.ihi.orghttp://www.ihi.org: Institute for Healthcare Improvement, tools to print, how to manuals http://www.healthdisparities.nethttp://www.healthdisparities.net: collaboratives done at HRSA clinics, Handbook for many chronic conditions (diabetes, asthma, CHF etc) http://betterdiabetescare.orghttp://betterdiabetescare.org: info for practitioners

25. Resources http://www.Improvingchroniccare.org Educational materials for patients http://www.ncdiabetes.org/ http://www.aace.com http://ndep.nih/gov http://www/cdc/gov/team-ndep http://www.diabetesatwork.org