1. Developing Workflow Process Diagrams To Target Interventions Moderator: Mindy Golatt, RN, MPH, Public Health Analyst, HRSA/HAB Presenters: Paul Cassidy, Program Director, GNBCHC Erika Harding, Health Administrator, CCHC Facilitator: Nanette Brey Magnani, NQC/HIVQUAL QM Consultant

2. Learning Outcomes Participants will be able to: Define the steps and symbols used in workflow process diagrams, Engage in discussion with grantees about their examples, and Begin to develop a workflow process diagram of their own work processes.

3. Agenda QI Principles and Framework Workflow Diagrams The Basics Examples Try it out! Post AGM Discuss and Revise with your Team.

4. Why Look at Processes? Fundamental Concept of Improvement: “Every system is perfectly designed to achieve exactly the results it achieves” Principles of Improvement: – Understanding work in terms of processes and systems – Developing solutions by teams of providers and patients – Focusing on patient needs – Testing and measuring effects of changes

5. Review: QI Principle Most problems are found in processes not in people.

6. Understanding Work in Terms of Processes and Systems Benefits Clearer understanding of the overall system and processes Target processes that need improvement Efficient allocation of staff and resources Effective use of team’s input and creative problem solving Better understanding of each other’s roles Reduction in waste and time

7. What are your initial thoughts about this improvement system?

9. When do you develop your workflow diagram? QI Project Steps Step 1: Review, Collect and Analyze Baseline Data Step 2: Develop a Project Team Work Plan Step 3: Investigate the Process/Problem Step 4. Plan and Test Changes – PDSA Cycles Step 5: Evaluate Results with Key Stakeholders Step 6: Systematize Change

10. QI Principle Most problems are found in processes not in people. – A system is made up of processes – Processes comprise steps

11. Workflow Diagram Definition A workflow diagram or flow chart is a picture of the steps of a process to: – Understand the process – Identify potential problem steps and reasons – Outline the ideal process steps – Enable communications with others

12. Creating a Process Diagram 1.Agree on use and level of detail 2.Define starting and ending points 3.Document each step 4.Follow each branch to the end 5.Review the chart. Flowcharts

13. Testing and Measuring a Workflow Process 1.Identify key problem steps. 2.Write key causes to each identified problem 3.Select interventions that address key cause. 4.Then test and measure new process. 5.Repeat as necessary. 6.Support new process – e.g. communication, new procedure guidelines.

14. Most Commonly Used Flowchart Symbols Activity/step Begin/ Terminator Decision Connecting lines Flowcharts

15. Grantee Examples VL Suppression Paul Cassidy – Greater New Bedford CHC, New Bedford, MA Gap in Care and Patient Transition to a different clinic Erika Harding – Christian CHC, Chicago, IL

16. Greater New Bedford Community Health Center, MA

17. Performance Measure for VL Suppression Percentage of HIV patients, regardless of age, with a viral load less than 200 copies/ml at last viral load test during the measurement year. Measurement year 2011

18. Number of Patients = 320 Suppressed (Blue)= 236 Not Suppressed (Red)=84 Suppression Rate=73% Baseline Data

19. Improvement Goal To increase patients’ viral load suppression rate from 73% to 85% in six months.

20. Causal Analysis Problem Steps with Workflow processes on two levels: Patient Level Insufficient time for adherence education for patients not suppressed

21. Causal Analysis cont’d Problem Steps with Workflow processes on two levels: Program Level Weekly (3x/month) multi disciplinary team meetings for patient review had stopped meeting for 6 months due to construction; thus a loss of focus on non suppressed patients Minimal input of multidisciplinary team members ideas into tailored care plans for each non suppressed patient No feedback loop for reporting results of the interventions back to the team.

22. Lab Blood Draw Call patient and make earlier visit than previously scheduled PATIENT REGISTERS MA TAKES VITALS PHYSICIAN EXAMINES PATIENT, REVIEWS RESULTS AND REGIMEN Review Meds, barriers to adherence, based on barriers, pre-pack meds, deliver to house, review meds and fill pill box Determine next steps with patient ** Give lab orders, patient to Lab Order Blood work for next three month review Schedule next visit Lab Results sent to Physician Lab Results Sent to RN Lab Results Sent to Data Entry. Blood work electronically entered into EHR Concern with Results No further Follow-up No further Follow-up Y N GNBCHC Workflow Process for Established Patients RN Adherence Visit Multi- Disciplinary Team Review <200 >200

23. RE- START WEEKLY MTGS-3/MONTH REVIEW PATIENTS TAKE NOTES DEVELOP CARE PLAN TEMPLATE DEVELOP PATIENT SPECIFIC CARE PLANS TEAM MAKES RECOMMENDATIONS ASSIGNED STAFF PRESENT PLAN TO PATIENT FOR PATIENT INPUT FOLLOW –UP ON RECCOMENDATIONS INTERVENTION IS INDIVIDUALIZED Prepare Reports Identifying Patients Not Suppressed. RN INTERVENTION DEVELOP AND IMPLEMENT CARE PLAN FOLLOW -UP SOCIAL WORK INTERVENTION FOLLOW-UP ON PLAN PEER NAVIGATOR INTERVENTION FOLLOW –UP ON PLAN SCHEDULED TEAM MEETINGS- REVIEW RESULTS OF INTERVENTIONS # OF PATIENTS WITH VL >200 REVIEWED # WITH TARGETED CARE PLANS PATIENT RESPONSE TO INTERVENTION DATA ENTRY GNBCHC WEEKLY MULTI DISCIPLINARY MTGS. *** BARRIERS TO VIRAL LOAD SUPRESSION SUBSTANCE ABUSE HOMELESSNESS NOT ATTENDING APPOINTMENTS MENTAL HEALTH ISSUES REFUSE MEDICATIONS

24. GNBCHC – Measurement Data Update

25. Christian CHC: Improvement Goals To reduce the gap in care rate from 13% to 5%. (number of patients with a medical visit in the last 6 months of the measurement year) To ensure 170 patients or 69% of our HIV+ population at the Monterey Clinic are successfully transitioned to the Halsted Clinic.

26. 26 Quality Improvement Team GROUP PHOTO HERE

27. 27 Patient Makes Appt.? Appt Kept. ? Patient Registers Repeat call from PHA Scheduler Transition Care from Monterey to Halsted CCHC Patients notified Instructed to make appt at different site Yes No YesNo Requires Follow-up Receives reminder call from PHA – 1 day prior

28. 28 Patient Follow-up Document status in list and chart PHA meets monthly with QI Team for patients’ status update Refer to Scheduler for appointment Import list of patients from CAREWare who’s last visit >45 days Note appt date in Patient Tracking Tool Yes No Patient Has a Scheduled appt? Active, Continuing? Yes No Data specialist initiates Patient Tracking Tool Refer names to Patient Health Advocate for follow-up

29. 29 Measurement Tracking Data Yr Ending Sept 2011 Nov 2011 Jan 2012 Mar 2012 Apr 2012 May 2012 Rate 13%16%18%7%6%8%

30. 30 Measurement Data Cycle 1 Ends Cycle 2 Ends Start PSDA Cycle 3 Ends

31. Task: Draw a Workflow Process Diagram 1.Select a process to improve. It can be just a few steps. 2.Agree on use and level of detail. 3.Define starting and ending points 4.Document each step. Use paper provided. 5.Follow each branch to the end 6.Review the chart. Flowcharts

32. Large Group DeBrief What improvement processes did you choose? Who will share your diagram? What were some of your challenges? What do you think are the benefits? What can you do post AGM? Flowcharts

33. REMINDER This is a TEAM effort! Flowcharts

34. Contact Information Paul Cassidy, Program Coordinator, Greater New Bedford Community Health Center, New Bedford, MA pcassidy@gnbchc.orgpcassidy@gnbchc.org Erika Harding, MPH, Health Administrator, Christian Community Health Center, Chicago erika.harding@cchc-rchm.org Flowcharts

35. Contact Information Mindy Golatt, RN, MPH, Public Health Analyst, HRSA/HAB, Project Officer/Chicago, mgolatt@hrsa.gov mgolatt@hrsa.gov Nanette Brey Magnani, EdD, Quality Management Consultant, NQC/HIVQUAL, breymagnan@aol.com breymagnan@aol.com Flowcharts