Xxxxxxxxxxxxxxxxxx xx Lessons Learned in MultiNetwork Quality Improvement

Xxxxxxxxxxxxxxxxxx xx Lessons Learned in MultiNetwork Quality Improvement

Xxxxxxxxxxxxxxxxxx xx Lessons Learned in MultiNetwork Quality Improvement Research Using Practice Facilitators Presenters Cheryl B. Aspy, PhD, OKPRN Melody Bockenfeld, MPH, WREN Lyndee Knox, PhD, LANET Carol Lange, MS, MAFPRN Paula Darby Lipman, PhD, Westat Workshop Goals Provide an overview of the CKD QI project;

Describe practice facilitation expectations for this intervention; Describe the data collected for both process and outcome evaluation of practice facilitation; Present 4 case studies of facilitation and lessons learned. Schedule Topic Overview Description of PF in context of QI interventions Expectations for this intervention re: CKD Study Brief intro of CKD study and PBRNs Description of the data collected for both process and outcome evaluation of practice facilitation Logic Model Small Group Discussion Recommendations for monitoring and evaluating practice facilitation. Share back with group Case studies of facilitation and lessons

learned Questions about Case Studies - Commonalities Goal Writing/Sharing How will you use the information youve heard today? Time Presente r 10 Cheryl 10 Paula 15 Cheryl/Paula 24 Melody

Cheryl Lyndee Carol Carol 20 Handouts Bios for presenters Logic model (CKD project) PF visit form (CKD project) Evaluation Checklist Resources and References Do you have questions about practice facilitation? If yes, write them down and pass them up

and we will get to them shortly. Practice Facilitation Defined PF is a supportive service provided to a primary care practice by a trained individual using a range of organizational development, project management, QI, and practice improvement approaches and methods to build the internal capacity of a practice to help it engage in improvement activities over time and support it in reaching incremental and transformative improvement goals.* Performed by: Practice Facilitators (PFs) Practice Coaches (PCs) Practice Enhancement Assistants (PEAs) PROJECT PURPOSE Wave I. Help 32 practices in 32 separate communities in 4 states implement National Kidney Foundation (NKF) Chronic Kidney Disease (CKD) Guidelines (KDOQI). We used an evidence-based multi-component

implementation strategy (performance feedback, academic detailing, practice facilitation, and IT support). Wave II. Each practice then diffuses new knowledge to two other practices through local learning collaboratives (LLCs) plus less intensive practice facilitation. CKD Background Information Stage 3 CKD occurs in 13% of the population CKD care consumes 19% of Medicare budget $57 billion CKD is a major risk factor for heart attack Similar to having a previous heart attack Kidney function over time A GFR loss of > 1L/min/year starting at age 25 can result in need

for dialysis within a normal lifespan Small change in the rate of GFR decline can result in large change in time to dialysis Lee A Hebert et al. Kidney International (2001) 59, 12111226 Guidelines Grade A evidence for reducing mortality or progression BP< 130 LDL<100 HgbA1c <7.0 Use of ACE inhibitors or ARB Guidelines Grade A evidence for reducing mortality or progression Avoid NSAIDS Smoking cessation

Referral to Nephrology for GFR <30 Avoid PICC lines for GFR <45 Medication Issues ACE/ARBS definitely help Low dose ASA still recommended by ADA and NKF FDA recommends discontinuing Bisphosphonates if eGFR is <30 Unclear what to do with Metformin STUDY TIMELINE 2010-2011 October March 2011 April January December June Study

Preparation Initial Data Collection 4 PBRNs LANet MAFPRN OKPRN WREN 8 Practices each = 32 Total 2012 Wave I Intervention/ Post Data

Collection Academic Detailing Performance Feedback Practice Facilitation IT Support Wave II Recruitment and Pre Data Collection Each practice recruits 2 more for Local Learning

Collaborative (LLC) = 96 Total 2012-2013 2013 March March April September Wave II Intervention / Post Data Collection

Data Analysis and Report Writing Academic Detailing Performance Feedback Practice Facilitation IT Support LLCs Evaluating PF Quality and Outcomes Westat is the Data Management and Analysis Center for the CKD Project Coordinate, manage, and analyze all data Intervention process Practice change Practice characteristics Outcome data collection from patient records

Includes quantitative (survey) and qualitative (interview, focus group) data collection Evaluating PF Quality and Outcomes Assessing the fidelity of implementation of your PF intervention Evaluating the outputs and outcomes Drawing conclusions about effectiveness Levels of Evaluation Local monitoring of fidelity to the intervention methodology Sharing lessons learned within your organization Participating in a multi-site evaluation CKD Study Evaluation Questions Has the CKD project ... Increased implementation of CKD guidelines through practice facilitation? (Aim 1)

Disseminated lessons learned through local learning collaboratives? (Aim 2) Shown improvement in practice change components (priority, capacity, content)? (Aim 3) Increased willingness and ability to participate in future QI projects (Aim 4)? Logic Model for CKD Project Graphic illustration of the relationship of inputs, outputs, and outcomes Clarify assumptions about the activities, interactions, relationships, and their assumed connections to the expected outcomes Guide data collection and analysis LOGIC MODEL: Leveraging PBRNs to Accelerate Implementation and Diffusion of CKD Guidelines in Primary Care Practices INPUTS OUHSC Dept of Family & Preventive Expertise and Research Evidence from 15 years of research activity

Other PBRN Partners WREN LANet MAFPBRN Analytic and Project Management Expertise Westat Multi-component Methodology for Quality Improvement Documented Effectiveness of Academic detailing, Performance feedback, Practice Facilitation, and IT Support Practice Facilitators (PFs) Practice Facilitators (PFs) Methodology/Training Methodology/Training Evidence based effectiveness Evidence based effectiveness Local Learning Collaboratives Local Learning Collaboratives Methodology/Training

Methodology/Training Evidence based effectiveness Evidence based effectiveness Information Technology Support Information Technology Support Other QI Expertise (Solberg) Other QI Expertise (Solberg) Knowledge/Skills evidence-based CKD Knowledge/Skills evidence-based CKD guidelines (Fox) guidelines (Fox) CONSTRAINTS of the Initiative Competing demands for: Competing demands for: Clinicians/Staff

Clinicians/Staff Patients Patients Current knowledge (clinicians/staff) of Current knowledge (clinicians/staff) of CKD screening guidelines CKD screening guidelines Lack practice change expertise within Lack ofofpractice change expertise within practices practices Limited QI resources Limited QI resources PROCESSES (ACTIVITIES) Hold regular Operations Committee Hold regular Operations Committee

Meetings for Planning and problem-solving Meetings for Planning and problem-solving Monitor progress Monitor progress WAVE I Implementation Intervention WAVE I Implementation Intervention Recruit 32 motivated, interested practice units Recruit 32 motivated, interested practice units across 4 networks across networks Train4practice facilitator Train practice

facilitator Enroll practices with informed consent Enroll practices with informed consent Practices complete initial survey forms Practices complete initial Conduct Initial interviewssurvey forms Conduct Initial interviews PFs audit charts for initial feedback PFs audit charts for initial feedback Provide Academic Detailing to 32 practices Provide Academic Detailing to 32 practices PFs provide Performance Feedback PFs provide Performance Feedback PFs facilitate practices across

months PFs facilitate practices across 6 6months visits every other week for 1 day visits every other week for 1 day PFs provide Monthly Performance Feedback PFs provide Monthly Performance Feedback to practices to practices PFs keep detailed diary notes of practice PFs keep detailed diary notes of practice visits visits Information Systems adapted to facilitate Information Systems adapted to facilitate

guideline implementation guideline implementation Complete required reports Complete required reports WAVE II Diffusion Intervention WAVE II 64 Diffusion Intervention Recruit additional practices in 4 PBRNs Recruit 64 additional practices in 4 PBRNs Collect initial performance data Collect performance data Set upinitial schedule for LLCs Set

up schedule for LLCs Conduct 32 monthly LLCs Conduct 32 monthly LLCs PFs continue practice facilitation for 24 PFs continue practice facilitation for 24 practices (3-4) visits per practice/ 6 months) practices (3-4) visits per practice/ 6 months) Conduct final chart abstractions that include Conduct

final chart abstractions that include data for pre and post time periods data for pre and post time periods Practices complete final survey forms Practices final survey forms Conductcomplete final interviews Conduct final interviews Clean data and prepare for analyses Clean data and prepare for analyses Analyze data Analyze data Write summary article for publication Write summary for publication Complete finalarticle

reports Complete final reports OUTCOMES PRACTICES PRACTICES Achieve 90% Achieve 90% implementation implementation of 10 key step of 10 key step estimated estimated outcomes in outcomes in Phase I- 85% Phase I- 85% in Phase II in Phase II Increased Increased

capacity for capacity for overall overall improvements improvements in CKD care in CKD care Increased Increased willingness and willingness and ability to ability to conduct QI conduct QI projects projects PBRNs PBRNs Increased capacity Increased capacity within PBRNs for

within PBRNs for collaborative collaborative quality quality improvement improvement projects projects CKD PATIENTS CKD PATIENTS A significant increase A significant increase in the number of CKD in the number of CKD patients who are patients who are diagnosed, treated, diagnosed, treated, and monitored and monitored according to CKD

according to CKD guidelines including: guidelines including: 1. Dx of CKD (GFR < 1. Dx of CKD (GFR < 60) 60) 2. Dx of anemia 2. Dx of anemia Metabolic control Metabolic control 3. BP 3. BP 4. Lipids 4. Lipids 5. HgbA1c 5. HgbA1c Starting helpful meds: Starting helpful meds: 6. ACE/ARB 6. ACE/ARB 7. ASA 7. ASA

Stopping harmful Stopping harmful meds: meds: 8. Metformin/ NSAIDS 8. Metformin/ NSAIDS 9. Hb Lab done 9. Hb Lab done 10. Labs Done - PTH, 10. Labs Done - PTH, Phos, or Vit Phos, or Vit PF Objectives CKD Project Meet with key members of each practice weekly and as needed to coordinate rapid QI cycles (Plan-Do-StudyAct). Document the visits, including who, when, where, and for how long, and the action plans and results of the cycles. Conduct monthly abstracts of the medical records of the last 10 CKD patients seen that month to give the practices feedback on their progress on the key action steps.

Help practices use tools from the toolkit, hold regular staff meetings, develop team-based protocols, registries, decision-support systems, and patient selfmanagement strategies. Evaluation Questions about PF (Aim 1) Develop a systematic approach to address questions such as: Who is the facilitator helping in the practice? What is the facilitator doing to help? What are the barriers and enablers of facilitation? What are the outcomes during the intervention? What are the outcomes after the intervention (sustainability, generalizability)? Contextual Factors Structural characteristics of practices

Size of practice Systems in use Attitudes, norms, and beliefs of staff Staff buy-in Climate within practice Stress Ability to make decisions about change Capacity and readiness for change Baseline performance History of change/prior history with PF Knowledge of the QI evidence PF Visit Form for CKD project Captures information on: Length and purpose of visit PF activities in practice Guidelines targeted Strategies planned and implemented PF and practice challenges

[handout] Two Part Evaluation FocusCKD Project The role of the facilitator: Goals what does the PF hope to accomplish this visits? Efforts what specific activities do they engage in? Achievements have they met their facilitation objectives? The role of the practice: * Goals what is the QI target? Efforts what is the level of effort? Achievements what strategies are they making progress on? * From the perspective of the PF PF Visit Form for CKD project Quantifiable research questions Frequencies Ratings

Qualitative research questions Text fields Descriptive data Quantifiable Research Questions Facilitator goals, efforts, and achievements How much time did you spend preparing for the practice visit? How much time did you spend at the practice on specific activities (e.g., chart review, observing, creating templates, meeting with clinicians, meeting with staff, providing feedback on implementation progress)? Did you meet your facilitation goals this visit? Qualitative Research Questions Facilitator goals, efforts, and achievements What were you trying to accomplish during this visit? What are your objectives for the next visit?

Quantifiable Research Questions Practice goals, efforts, and achievements What guidelines is the practice working on? What is your rating of practice effort between visits? What is your rating of practice progress between visits? On what strategies has practice made progress since last visit? (e.g., patient self-management, delivery system design, decision support, information systems) At what phase of the PDSA cycle is each strategy? (plan, do, study, adopt/adapt/abandon) Qualitative Research Questions Practice goals, efforts, and achievements What was the practice atmosphere during the visit? Describe the nature of the progress the practice has made (on a strategy). What will the practice try to accomplish by the next

visit? Positive Indicators of Impact Participation/engagement of practice staff Continued investment from the QI champion Effort continues within the practice between visits Enthusiasm may extend beyond the focus of the QI project Staff want the project to continue There is interest in working again with the PBRN Achieving the QI Goals Providing monthly audit data Retrospective medical record audits Preliminary Findings: Guidelines # (%) of visits in which practice was working on guideline (Wave I)

OKPRN Total # of visits eGFR in chart Addition of appropriate meds Removal of inappropriate meds Labs Prevention/ Patient education Other (e.g., registry) None

(at this visit) OK01 17 3 (18) 13 (76) 12 (71) 13 (76) 10 (60) 0 3 (18) OK02 23

2 (9) 16 (70) 15 (65) 4 (17) 14 (61) 3 (13) 1 (4) OK03 20 4 (20) 12 (60)

10 (50) 4 (20) 12 (60) 3 (15) 4 (20) OK04 25 0 14 (56) 13 (52) 24 (96) 16 (64)

1 (4) 1 (4) OK05 22 0 9 (41) 8 (36) 19 (86) 9 (41) 0 3 (14)

OK06 17 0 2 (12) 2 (12) 14 (82) 11 (65) 13 (76) 1 (6) OK07 19 1 (5)

11 (58) 10 (53) 17 (89) 10 (53) 0 1 (5) OK08 27 4 (15) 2 (7) 2 (7)

4 (15) 5 (19) 22 (81) 1 (3) 17-27 0-20% 7-76% 7-71% 15-96% 19-65% 0-81% 3-20%

Range Preliminary Findings: PF Activities #(%) of visits in which PF activity took place (Wave I) OKPRN Total # of visits Abstracting records Observing Meeting with clinicians Informal meeting with staff OK01

17 6 (35) 5 (29) 4 (24) 8 (47) OK02 23 9 (39) 10 (43) 9 (39) 15 (35) OK03

20 7 (35) 8 (40) 7 (35) 8 (40) OK04 25 18 (72) 15 (60) 18 (72) 8 (32)

OK05 22 9 (41) 14 (64) 7 (32) 1 (5) OK06 17 10 (59) 11 (65) 3 (18) 1 (6)

OK07 19 14 (74) 13 (68) 15 (79) 6 (32) OK08 27 10 (37) 3 (11) 10 (37)

6 (22) 17-27 35-74% 11-68% 18-79% 5-47% range Small Group Discussion & Report 1. In small groups, select a reporter 2. Develop 3 recommendations for ways to monitor and/or evaluate practice facilitation or practice facilitators 3. Reporter shares with large group Small Group Ideas

Small Group Ideas NAPCRG Small Group Ideas Diversity of training of practice facilitators dont know who you get Its hard to standardize personalities both on the practice side and facilitator side especially with distance facilitation We dont have a hypothesis driven idea of how to measure the effect of the practice facilitation Exposure of facilitators to practice issues how practices implement guidelines With distance facilitation, the practice is still meeting after you hang up NAPCRG Small Group Ideas Want an accounting for how many people you talk to Feedback from the practice about the PFs effectiveness Does facilitator have the analytic ability to

understand needs of practice, anticipate next steps? Is the PF understanding where the practice is and where to go with the practice for the next meeting- does that difference allow you to identify a good PF from one that is not as effective NAPCRG Small Group Ideas Supervisory challenge because not observing the PF role directly Training and professionalism how do you relate to the practice staff (develop a relationship) and maintain professional role? How important is the relationship the t the individual PF has with the practice interchangeable with other PFs? Four Case Studies of Practice Facilitation

WREN OKPRN LANET MAFPRN The WREN Experience Multiple Transitions during project 3 of 4 Practice Facilitators (RRCs) new at start of project Practice Facilitator turnover during project New Network Manager New Director Good mix of long term member practices and new practices The LLC framework grew our network WREN CKD Practices Practice Sites UW Practices Part of a large

health system Federally Qualified Health Center Free Clinic Total sites Wave I 3 3 Wave II 6 5 1 3 1 8 0

14 Geography: (WREN on the MOOve) Wave I Wave II Top 5 Lessons Learned 1. Create a Learning Collaborative among Practice Facilitators Development of chart audit feedback processes Weekly meetings to discuss progress at sites Practice Facilitators shared data reporting formats, report templates, novel implementation ideas Discussed strategies to deal with challenges and barriers 2. Customize Facilitation for Each Site

Identify what decisions can be made within the practice vs. health system administration Get to know the practice WI practices were large Not receptive to the idea of practice facilitator in clinic day per week Put the right team together 3. Build sustainability into practice improvements Assist clinics to develop work flows around CKD practice improvements and assign accountability Facilitate adoption of EHR changes Registries

Alerts Standard order sets Patient education materials 4. Capitalize on training opportunities for practice facilitators UW Quality Improvement Website Joint training with UW Microsystems staff, Coaching self-assessment Practice Facilitation webinars 5. Good Practice Facilitation Takes Time Chart audit feedback a helpful tool, but facilitating the development of new processes most important Single Academic Detailing meeting not always enough to assure understanding of guidelines Practice facilitators found ways to emphasize relevant guidelines during monthly feedback meetings

OKPRN Case Study Location of 8 Original CKD Practices OKPRN Project Realities Small practices - often a single provider Experienced PFs each with more than 9 years experience working in OKPRN Previous relationships with many of the clinicians Long travel times for PFs PFs dedicate one day per week to administrative activities Paperwork, e.g., reimbursement forms for clinics Review notes/progress with supervisor Typical OKPRN Facilitator Schedule 8 practices per facilitator per 6 month project cycle day per practice per week so 4 days per week in practices

1 day per week in the Department 30 minute individual debriefing session with supervisor to discuss progress in each practice and specific challenges 1 hour group meeting to review each ongoing project (typically 5-6), with an emphasis on logistics (enrollment, milestones, challenges, opportunities, etc.) 1 hour training 5 hours to catch up on paperwork, research for the practices, scheduling, etc. Visit Notes Capture Process measures Time preparing for the visit Time in practice - (We believe that it is important for the facilitators to spend a half-day in each practice, even if they have nothing specific to do.) Broken down into specific types of activities Perception of progress made toward meeting objectives

Lessons Learned Having a previous relationship with a practice can be either a facilitator or detractor, e.g., Clinicians change practice affiliations Staff turnover within practices is very high Outsider role suggests change Insider role sympathizes with difficulty of change Requires continual training/updating regarding project goals/responsibilities

Making Changes to EHR templates and changing laboratory reporting processes can be a challenge LA Net Case Example L.A. County Location of Wave 1 practices LA Net Project Realities Sites: 5 Multi-site FQHCs 1 small CHC 1 small safety net private practice All focused on: EHR implementation (est. $1 mil loss in 1st year) PCMH transformation/recognition

Visit every 15 minutes SPD patient transition Loss of CMO or champion at 5:8 sites Not that interested in CKD . LA Net process Step 1: Academic Detailing visit - Created Buy-in! Step 2: Get data Took forever! 6 months: 6 months Step 3: Present data to practice team Patient'Aligned'Care'Team'(PACT)'Metrics Present data to practice Provider:'JOHN'DOE Category Metric Panel' Management

Apr'12 May'12 Jun'12 Jul'12 Aug'12 Sep'12 Oct'12 Nov'12 Dec'12 Jan'13 Feb'13 Mar'13 Access Secure' Messaging Continuity Coordination' of'Care 100%# Ra#o% of% PC% Telephone% Encounters/All% PC%

Encounters% 100%# Same% Day% Appts% w/% PC% Provider% Ra#o% 90%# 80%# 80%# Goal:& 70%# 70%# 60%#

60%# 50%# 40%# 40%# 30%# 20%# Goal:& 20%# 20%# 10%# 0%# 0%# Apr#12# May#12# Jun#12# Jul#12# Aug#12# Sep#12# Oct#12# Nov#12# Dec#12# Jan#13# Feb#13# Apr#12# May#12# Jun#12# Jul#12# Aug#12# Sep#12# Oct#12# Nov#12# Dec#12# Jan#13# Feb#13# Mar#13#

100%# Con#nuity% PCP% 90%# 80%# 70%# 100%# [email protected] day% Contact% Post% Discharge% Ra#o% 90%# Goal:& 75%#

80%# 70%# 60%# 60%# 50%# 50%# 40%# 40%# 30%# 30%# 20%# 20%#

10%# 10%# 0%# Goal:& 50%# 0%# Apr#12# May#12# Jun#12# Jul#12# Aug#12# Sep#12# Oct#12# Nov#12# Dec#12# Jan#13# Feb#13# Mar#13# Apr#12# May#12# Jun#12# Jul#12# Aug#12# Sep#12# Oct#12# Nov#12# Dec#12# Jan#13# Feb#13# LA Net process Step 1: Academic Detailing visit - Created Buy-in! Step 2: Get data Took forever! 6 months: 6 months Step 3: Present data to practice team Step 4: Support changes Support changes

A. HIT OPTIMIZATION REGISTRIES. Set-up CKD patient registry and reporting for panel management and QI I2I tracks OCHIN report - $1200, 6 months to produce DATA MAPPING. Identify and correct mapping errors in EHR PERFORMANCE REPORTS. Performance reports at provider level on CKD metrics TEMPLATES/REMINDERS. Set-up templates and alerts TECHNOLOGY BASED HEALTH EDUCATION FOR LOWLITERACY Individualized health education using tablets/video

LIAISON W/ VENDORS. Correct registry product for AA CKD norms Support changes B. Changes to clinical processes Change order sets add eGFRs Workflow mapping (which is mainly EHR mapping) C. Clinician support Project ECHO Knowledge Network on CKD (more academic detailing) Lessons Learned from Wave 1 Improvement work is mainly about 2 things: personalities & technologies Academic Detailing at the beginning of an improvement effort is vital Data are still enormously hard to get but also vital --- budget sufficient funds and time to get it Processes like PDSAs are insufficient to drive change need more robust models (Agile

Development as a model) Lessons learned from Wave 1 Larger organizations are more difficult to affect with a traditional PF--- but have the HIT and data systems PFs in these environments need deep skills in HIT Smaller practices benefit more from PFs --- but lack the HIT and data systems PFs in these environments need skills in making do, reigning in unsustainable workarounds (hand entered registries), and finding low cost HIT resources Lessons learned from Wave 1 CMOs must be kept in loop weekly or monthly even if they delegate PFs need to be monitored closely for support needs, and to assure follow-through its easy for them to stop pushing esp. in large settings Liaise with the leadership

Make sure work is focused on high impact Engage IT staff Projects need to be mapped to PCMH, Meaningful Use, and PFP to get real uptake by orgs. MAFPRN Case Study Work within Health Systems MAFPRN Participating Clinics Wave I (Red) 3 Urban 1 Suburban 4 Rural Wave II (Blue) 6 Urban 2 Suburban 6 Rural PF in Health Systems MAFPRN Experience

Health Systems dominate care delivery Increased in 2011 to present as prepare for ACOs Urban area mergers of Health Systems Rural areas remaining independent practices/hospitals selling PF in Health Systems Previous work with practices a key success factor. System Medical Director has significant role. Conflicting demands including EMR changes, staffing cuts, PCMH certification, other clinical performance measure reporting impact role of PF. Two scenarios: Wave II not allowed to continue vs Wave III with sharing training/tools at Clinical Practice Committee. PF in Health Systems Scenarios Wave II practices not allowed to continue in two systems

Clinics closed/merged System expanded project to include all clinics using work flows, pre-visit planning, order sets. Used internal QI staff as part of PF team for the project. Small Group Discussion What Common barriers and opportunities do you see among the four examples? How do you plan to use this information? Write a goal statement incorporating your plan. Example: By the end of January, I will have developed an evaluation plan for my practice facilitation project that will address ways to monitor and assess how PFs spend their time in practices. Large Group Small Group Reports Summary

PBRNs are using PFs increasingly Evaluation of PFs may include the following: Process documentation Outcome documentation Qualitative documentation Source of Data may include PF documentation of visit Survey data (Practice and staff) Chart Audits Focus Groups

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