Optimizing Primary Care: IHI Principles

1. Optimizing Primary Care: IHI Principles Increasing Supports for Family Physicians in Primary Care A CFPC-HC Project November 26, 2006 Toronto, Ontario

2.  Commission on the Future of Health Care in Canada. Building on Values: the Future of Health Care in Canada (Romanow, Ottawa: 2003) � Standing Senate Committee on Social Affairs, Science and Technology. The Health of Canadians � the Federal Role, Final Report on the State of the Health Care System in Canada (Kirby, Ottawa: 2003) � Alberta, Premier�s Advisory Council on Health. A Framework for Reform. (Mazenkowski, Edmonton:2001) � Saskatchewan Commission on Medicare. Caring for Medicare, Sustaining a Quality System (Fyke, Saskatoon: 2001) � Ontario Health Services Restructuring Commission. Looking Back, Looking Forward, A Legacy Report (Toronto:2000) � Quebec Study Commission on Health Services and Social Services. Emerging Solutions, Report and Recommendations (Quebec:2000) � Health Services Review Committee. Fredericton:1999) Jeffery Simpson, Globe and Mail editorial, Jan 8, 2004 �New script, same old play?� �Reform primary health care.� (pick a model, any model)

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4. Goals of Primary Care Renewal in Canada Improving frontline access to healthcare Ensuring the continuity and comprehensiveness of care for patients Increasing patient and provider satisfaction Improving the quality of care for patients Increasing the cost-effectiveness of healthcare services. Preserving the doctor-patient relationship as central

5. Federal-Provincial Primary Care Initiative Objectives Increase the proportion of residents with ready access to primary care. Provide coordinated 24-hour, 7-day-per-week management of access to appropriate primary care services. Increase the emphasis on health promotion, disease and injury prevention, care of the medically complex patient and care of patients with chronic diseases. Improve coordination and integration with other health care services including secondary, tertiary and long-term care through specialty care linkages to primary care. Facilitate the greater use of multidisciplinary teams to provide comprehensive care.

6. IHI Principles �Deliver the best care, in the best way, on time, every time.�

7. IHI Principles Access Continuity and Comprehensiveness Quality Care Safety and Reliability

8. Context: Where we have been- Taber Health Project � 2000 Chinook Chronic Disease Network- 2002 �Good Health Teams� Pincher Creek- 2003 Chinook Primary Care Network - 2006 Move thro dividing the work thro speciality to panel. Got good at teams, but need to go thro to provider/a\panel Concept of FP as speciality New chance to do it again. Move thro dividing the work thro speciality to panel. Got good at teams, but need to go thro to provider/a\panel Concept of FP as speciality New chance to do it again.

9. Alberta Primary Care Networks 2006 One of 14 PCNs so far in Alberta 537 family doctors, 18% of the population Chinook Primary Care Network Joint Venture Agreement between the RHA and physicians 15 independent clinics, 9 rural and 6 urban patient population of 184,000 97 out of 99 FPs in the region Focus on Enhanced Access and office/community based �Family Practice Teams� Initially, the first 3 changes only. Took huge effort and emotional energy for everybody But did nothing for Mrs Smith It was not until we were into the project a yr and had these in place that we realized what this was all about-namely that these supports were only the infrastructure, the supports we needed to take care of Mrs Smith differentlyInitially, the first 3 changes only. Took huge effort and emotional energy for everybody But did nothing for Mrs Smith It was not until we were into the project a yr and had these in place that we realized what this was all about-namely that these supports were only the infrastructure, the supports we needed to take care of Mrs Smith differently

10. Current Environment Hospital bed closures with shorter stays, along with longer waits for specialist referrals, investigations, admissions, and procedures Resulting in increased pressures on community resources, family physician offices, public and community care nursing, mental health and rehab services, and the list goes on. Severe and continuing shortages of health human resources has made for a pressurized and unsatisfying working environment. Recruitment and retention has become a major concern.

12. The Problem Despite all our best efforts - Using our traditional medical model, and the resources currently available to us, we have been singularly ineffective in meeting targets and providing �guideline level care�. There are few existing tools or models that support: Inter-professional models providing multi-dimensional care Team based services within an office setting Patient education that empowers self care We knew that there was a problem that there were There was no existing tool to support: Inter-disciplinary care Team based service Self-care focus We knew that our teams, all had the clinical practice guidelines but how do you distill this down into something that everyone can use and find useful. We also knew that much of the information around clinical practice guidelines have valuable tools for the specialist or specialty programs with no concerted focus on inter-disciplinary / team based care that promotes client self careWe knew that there was a problem that there were There was no existing tool to support: Inter-disciplinary care Team based service Self-care focus We knew that our teams, all had the clinical practice guidelines but how do you distill this down into something that everyone can use and find useful. We also knew that much of the information around clinical practice guidelines have valuable tools for the specialist or specialty programs with no concerted focus on inter-disciplinary / team based care that promotes client self care

14. �Every system is perfectly designed to get the results it gets.� We have perfected how to �work alone together�, one visit at a time.

15. How Do We Achieve These Primary Care Objectives? This will require a systematic redesign of how we do our work. We need: Improved access to family physician clinics. Improved operational and clinical efficiency in order to increase capacity and productivity. Improved quality and clinical outcomes. Leadership focused on Clinical Excellence. We recognize that we will need more capacity and productivity in an environment with chronically scarce providers Notice no mention of improved lifestyle anymoreWe recognize that we will need more capacity and productivity in an environment with chronically scarce providers Notice no mention of improved lifestyle anymore

16. Office Practice Redesign Goals Access Reduce delay for appointments to same day Reduce delays within the appointment x 30% Continuity Increase continuity of care x 90% Increase capacity (panel size) x 10% Quality Outcomes Increase utilization of selected protocols and guidelines Improve interdisciplinary team utilization and function. Safety and Reliability Continuous Measurement of this process and outcomes

17. Principle: Access �Without access there is no quality.� Dr. Jonathan Perlin, MD, Under Secretary for Health

18. What is the Canadian Public saying? 80% prefer to access care through their own FP Stats Canada, Access to Health Services Delivery Survey, 2001 16% of Canadians are unable to find a family doctor. CFPC October 2006 Even when they can find a doctor, there are excessive wait times for an appointment and at the appointment.

20. Process for Improving Access and Capacity STEP 1: Formation of a local change/improvement team in your clinic: Create a clear and shared vision: Why does this practice exist? Build an intricate understanding of the �big picture� (Providing the best care, in the best way, on time) as well as the �small picture� -clearly defined roles for the individuals in the clinic and beyond. Know your patients (Demand)

21. Process for Improving Access and Capacity STEP 2: Know your people/staff (Supply) Know your processes (Demand) Wait times for appointments Patient time spent at the appointment Several assessment tools exist to help. www.clinicalmicrosystems.org/access.htm

22. Access and Capacity �The most effective systems (clinical outcomes), and the most efficient systems (cost-revenue), with the most satisfying systems for patients and providers match demand to supply with as little delay as possible.� Delay leads to dissatisfaction, mistakes, and suboptimized productivity/cost Balanced demand and supply must occur at the system level, the practice level, and the individual provider level.

23. If Demand > Supply

24. Demand=Supply

25. Demand=Supply

26. Taber Clinic Weekly Demand and Supply

27. Taber Clinic Time to Third Next Appointment Providers have agreed to go to same day access by November 7, 2006. Providers continue to work on backlog.Providers have agreed to go to same day access by November 7, 2006. Providers continue to work on backlog.

28. Principle: Continuity and Comprehensiveness See your own patients. Don�t make them wait. (Goal: increase capacity x 10%)

29. What is the Canadian Public saying? Canadians want a personal physician, one that knows their history and that of their family, and one with whom they can build a relationship over time. Macleans poll 2003 The most valued qualities: �human relationships� �time to care� the �opportunity to share decisions�.

30. Process for Improving Continuity and Comprehensiveness Step 3: Identify your defined patient population Assess their demand (ie return visits based on morbidity) Assess your supply Assess your continuity % of patients I see that are mine % of my patients that see other doctors.

31. Process for Improving Continuity and Comprehensiveness When patients see their own physician, patient and clinician and staff satisfaction rise, costs go down, revenue rises, and clinical care and outcomes improve. Visit length is shorter and outcome is better. Chance of �re-visit� goes down Re visit rate is 2 x higher if patient sees an �allied� provider. Re visit rate is 4 x higher if patient sees a unallied provider (ER) Increased sense of ownership by provider, patient and team.

32. What is a Panel? = a unique, unduplicated, discrete patient population for which he/she is responsible. In an 8 physician clinic for example, Each physician is responsible for their unique grouping The total grouping for all 8 physicians would then circumscribe the entire clinic population

33. Why a Panel? Visit �demand� is predicted by: Panel size Panel composition (age and gender) Return Visits Number of visits needed are then predictable (we know about 1% of the panel will request a visit each day) Supply= available appts/day x days worked/year Demand and supply can be balanced System knows how many doctors are needed

35. Advantages of a panel Patients know their Family Doctor Doctor knows �which patients are mine� Both feel accountable to each other. The team is in a position to supplement that dyad in order for it to be successful Preventive and chronic disease care needs can be clearly identified, as well as acute and urgent care Appropriate incentives can be developed for access and quality

37. Taber Clinic Supply/Demand

38. Principle: Quality of Care �Quality clinical care is not doctor work, it is team work.� �The best clinical care is not delivered by physician visits alone�

39. Process for Clinical Improvement STEP 3: Implement change principles to guide the improvement work.

40. Change Principles Optimizes the utilization of teams that support physicians in the work they do everyday within the family practice environment. Core family practice teams, including Regional services Supports the care of a defined population of patients Standardized, supported team care, linked to the provider with clear accountability and leadership.

41. Burning Questions What is our current team number and composition? How many support staff are needed in our practice/program? How many will improve productivity? How many will improve outcomes? What professional types of person is best? NP/RN/LPN/MA/Other? Social worker, case manager, other?

42. Family Practice Team Duties Family Practice Teams support not only WHAT care is provided, but HOW it is provided. Operational Teams � HOW care is provided. Gets the patient, and the patient work (lab results, etc) to the provider in time. Process, space/staff use, and office redesign Clinical Teams� WHAT care is provided. What is the clinical work that the patient population needs? What protocols and guidelines do we need?

43. Do Patients Notice Good Teams?

44. Change Principles Identify the �high leverage� clinical areas that improvement will have greatest impact on improved clinical outcomes. Implement clinical protocols and guidelines to assist the team and reduce variations in practice. Develop specific, measurable performance indicators to evaluate success.

45. Principle: Reliability and Safety �Safety is connected to Delay�

46. Process for Improvement STEP 4: �Metrics Matter� �Drumbeat of Change� Routinely measure and compare Demonstrate the changes made and effort extended actually resulted in improvement Some excellent measurement tools are available www.clinicalmicrosystems.org www.improvingchroniccare.org www.howsyourhealth.org

47. Outcome Measures Access measures: Time to third next available appointment Continuity measures: % of patients that see their own doctor Preventive Measures: Screening for Breast, Cervical, and Colon cancers Clinical Measures: hypertension Diabetes Smoking cessation Immunizations

48. Mary�s Story Mary, a 64 year old women with diabetes, comes for her regular 15 minute appointment with Dr. L.  After evaluating Mary�s acutely painful knee and her stomach reflux disease, Dr. L has 3 minutes left to assess her diabetes and high blood pressure control and management. He quickly checks blood pressure, which reveals a significantly high result.  Dr. L searches for Mary�s most recent lab work in her medical record to find her last blood sugar and cholesterol results. He only finds pieces of the information, and in frustration, schedules another visit for Mary in three weeks.

49. Mary�s Story Dr. L thinks he may have made a referral to the diabetes program but did not have time to look for any notations.Mary does not keep track of her blood sugar results or follow any particular plan to manage her diabetes. Mary has had high blood pressure for 20 years, elevated cholesterol and is overweight. Mary books her next appointment on her way out the door.

50. Johns� Story John, a 76 year old semi-retired farmer, arrives for his regular planned appointment. John has had hypertension, diabetes and some signs of early congestive heart failure. At his previous visit he discussed his painful right shoulder and inability to sleep at night. John first meets with Leslie, the family practice nurse, located in Dr. H�s clinic. Leslie takes John�s blood pressure, finds his most recent lab results on the computer and scans his home glucose results into the medical record.

51. Johns� StoryDr. H joins John and Leslie, and reviews the reminder messages that show he is now due for his annual eye examination and lab work to screen for renal complications. Leslie orders these requests on the computer and a copy is printed for John. Dr. H prints a graph showing the last 2 years of John�s blood sugar tests and cholesterol levels.  John tells Dr. H about the series of classes he and his wife have been attending on healthy eating, keeping active, and on managing his diabetes. He has been learning how to adjust his insulin for different meals.

52. Johns� StoryDr. H reinforces how well John�s self-management plan is working, and asks him to touch base with Leslie the nurse after he completes his classes. John is encouraged to contact Leslie and/or the local on-site regional vascular protection team if he needs assistance in self insulin adjustment while he is learning.  He can also call the front desk to get his blood results in a few days.  Dr. H books a 3 month follow-up to see John.

53. Take the leap�. we will build our own wings on the way down. Donald Berwick

54. References Institute of Healthcare Improvement www.ihi.org CFPC Primary Care Toolkit http://toolkit.cfpc.ca Chinook Primary Care Network www.chinookprimarycarenetwork.ab.ca Professional Login: User ID: primarycare Password: health2006