Redesigning the Patient Visit - A Core Element

The model for this Collaborative combines an iterative, process improvement approach with fastpaced change brought about through reengineering. The first cycle of this evolving model (in five cluster specific collaboratives) has been successfully implemented by centers across the country to improve patient visit cycle time, productivity, and patient satisfaction. The basic premise of the Collaborative model is that to be competitive in today’s healthcare market requires a redesign of the core business (e.g., patient visits) and the use of existing knowledge and experience to guide design efforts. Another distinctive feature of this Collaborative is the focus on patients needs and desires as drivers of health center change efforts. By taking a redesign approach, results will be achieved organization-wide as opposed to within one department or area. This strategy assumes that health centers are not bound by the current system, that they can effect changes identified as useful, and that they desire a system that is efficient, effective, and delightful for both patients and staff. Health centers selected to participate in these Patient Redesign Collaboratives will identify their team, in collaboration with the Project Director 6-8 weeks prior to the beginning of each Collaborative. Teams will have 4 to 5 weeks to complete pre-work exercises that include readings on reengineering, and mapping of patient visits and cycle times. Teams from each participant center will then join together with the Collaborative’s Expert Panel for the first of three didactic learning experiences (Learning Session One). Each team upon return to their center (Action Period One) will apply skills and information gained from this Session. Teams, and the Executive Director from each participant center, will then come together for additional learning, sharing, and refocusing (Learning Session Two). Teams will return to their centers to continue redesign efforts (Action Period Two). All teams will come together for final sharing and closure at Learning Session Three.

Participant health centers can expect to achieve a competitive advantage, as well as results that will drive the agenda of future Quality Center Breakthrough Collaboratives. The learning and knowledge that result from this Collaborative will be disseminated to the larger audience of health centers and health care organizations for adoption and replication.

The Patient Redesign Collaboratives continue to achieve major results. Cluster specific redesign collaboratives are concurrently preparing our systems for rapid change. Through learning sessions completed in all five clusters, 75 health centers have successfully completed a collaborative. Participating teams have
accomplished major transformations in service quality and outcomes, with an average decrease in cycle time of 55 percent and an increase in productivity (patients per clinician per hour) of 40 percent. Most importantly,
these system changes have resulted in patients experiencing more time with their clinical team, with an increase in this “value-added time” of 56 percent successes have been documented to improve patient and staff
satisfaction and are sustainable over time. The introduction of redesign principles, to 170-Bureau supported
sites has been accomplished in several ways; through redesign collaborative learning teams introduction of a free standing “starter kit” (in partnership with the Office of Managed Care) as well as locally supported mini-collaboratives partnerships.

The Health Disparity and Redesign Collaboratives are part of the effort to coordinate the wide variety of clinically focused activities into a coherent strategy, now encompassed under the Excellence in Practice objective of the strategic plan. A number of ongoing activities, as well as those presented here are components of a far-reaching effort to transform the way care for the underserved is delivered in this country. This Policy Information Notice outlines performance driven activities which include four key elements: the transformation of practice through models of care, improvement and learning; an infrastructure and support system to sustain and spread
positive change; the development and nurturing of interdisciplinary leadership; and strategic partnerships.

Program Objectives:

Goal: The aim of the Patient Redesign Collaborative is to dramatically reduce cycle time for patient visits to the health center by redesigning the patient medical visit. The collaborative will assist each participant organization to achieve a competitive advantage by accomplishing the following goals:

Improve quality by: reducing the amount of time patients spend in the health center while simultaneously maintaining or enhancing the amount of quality interaction with staff. Reduce costs by: increasing provider and staff productivity. Increase productivity: by reducing rework, eliminating waste, and simplifying the system.

The Redesigning the Patient Visit Collaboratives are intended to accomplish three critical aims:

• To generate and document improved access for underserved populations by creating patient centric systems of care that are effective and efficient,
• Transfer knowledge about how to design and implement radical reengineering principles in BPHC delivery sites; and,
• Develop infrastructure, expertise, and leadership within the participating organizations to support and drive redesign quality improvement.

To accomplish these aims, the goal is to involve all health centers and a significant number of special populations and NHSC free standing sites during the next 3 years in at l year least one collaborative learning experience dedicated to patient visit redesign. Continued access to redesign expertise will be provided to participating health centers in their post-collaborative work.

Collaborative Goals

• The aim of the Patient Visit Redesign Collaborative is to dramatically reduce cycle time for patient visits to the health center by redesigning the patient medical visit. The Collaborative will assist each participant organization to achieve a competitive advantage by accomplishing the following goals:
• Improve quality by: reducing the amount of time patients spend in the health center while simultaneously maintaining or enhancing the amount of quality interaction with staff. Reduce costs by: increasing provider and staff productivity.
• Increase productivity: by reducing rework, eliminating waste, and simplifying the system.

Health Center Participation Requirements

Executive Directors of health centers participating in this Collaborative must commit to:

• Engaging health center staff in efforts to reduce medical visit cycle times (the time from when a patient walks in the health center door to the time they walk out).
• Participating in the full duration of the project:
• Working with the Collaborative Director to select a team of 4 to 5 staff to participate in this effort (while membership will vary by site, possible participants include front desk personnel, managers, nurses, and providers; a team must include a provider which is defined as a physician, nurse practitioner, or physicians assistant).
• Ensuring selected team members have 6 to 8 hours Aoff-line@ scheduled each week for the duration of the Collaborative.
• Sending the entire team to three Learning Sessions and the Executive Director to the second and third Learning Sessions.
• Completing pre-work requirements prior to the team’s attendance at the first Learning Session.
• Paying for all travel related costs to send team members to the three Learning Sessions required by the Collaborative (estimated costs: $5,000 - $6,000). Optional travel costs may be incurred through site visits to other participant organizations.
• Providing the team with access to electronic mail (email), the primary communication tool to be used by the Project (direct email communication between the team and Project Director is required prior to participation in the first Learning Session).
• Agreeing to meet with the team biweekly.
• Sharing experiences and data openly so that knowledge and learning can be summarized

Expert Panel

The Patient Visit Redesign Collaborative will be led by an Quality Center’s National Redesign Expert Panel comprised of individuals experienced in redesigning health center patient visits, applying process improvement approaches, and providing clinical care. This team will coach health center teams in their redesign efforts using telephone, email, and other support, as necessary.

Responsibilities of Lead Organization

1. Identification and management of Cluster-Specific Applicant Review Panel in cooperation with Cluster Collaboratives Steering Committee.
2. Formation and support of the Cluster-Specific Redesign Expert Team for each collaborative in conjunction with National Redesign Expert Team.
3. Coordination, planning and implementation of learning sessions in conjunction with National Redesign Expert Team.
4. Documentation of learning session evaluations and results.
5. In collaboration with the National Redesign Expert Team, development of strategy and ongoing support and spread of redesign efforts.
6. In collaboration with BPHC convene a planning group to draft a strategy to coordinate and integrate health disparities and redesign collaborative infrastructure and content. The strategy is to include an aim statement, designing and implementing test cycles, and a plan for implementation beginning in FY 2002. Resources and support for three planning group meetings, facilitator and appropriate technical assistance should be reflected in the budget submitted to BPHC.

Together for Tots Transition to Health Disparity Collaborative in Fiscal Year 2001 - 2002

The purpose of this section is to:

1. Announce the transition of the Together for Tots (TOTs) program to the Health Disparities Collaborative format during fiscal year (FY) 2001 - 2002;
2. Inform the Primary Care Association (PCAs) and clinical network communities that for FY 2001 the immunization program will continue to be funded directly.
3. Inform the PCA and clinical network communities that only one person will be supported to attend the Collaborative training and conferences from each of TOTs PCAs;
4. Outline program requirements for participation in the transition year;
5. Outline the format to be used in preparing the Letter of Intent to participate; and
6. Announce that for FY 2001, the budgets will include a 5 percent increase over FY 2000.

PROGRAM REQUIREMENTS
To continue to participate in this initiative, PCAs and Clinical Networks must submit a "Letter of Intent," which should not exceed five pages in length, describing planned activities and methods for accomplishing them and a one page itemized budget request and justification.

I. To be eligible to participate in the Health Disparity Collaborative, PCAs and Clinical Networks must:

• Have a written contract or agreement with the lead cluster PCA outlining responsibilities of both partners. This agreement must include plans for training and mentoring of Collaborative Coordinators by the lead Cluster Collaborative Director and participation in cluster Collaborative Steering Committee. The
  agreement will also include the integration of the cluster monthly report for Health Disparity Collaborative narrative and measures when the Prevention Collaborative pilot is launched.
• Have 1.0 Full Time Equivalent (FTE) dedicated to Health Disparity activities, which includes the immunization program.
• Provide evidence of collaboration between the PCA and clinical network or committee, with a documented track record of activities that have improved clinical practice and outcomes. The PCA must have a governance structure with significant representation by a group of clinicians with active practices in health
  centers or NHSC sites, or have a plan to phase into such a structure within the next 12-18 months. A letter of support from the clinical network or committee should accompany the Letter of Intent.
• Submit quarterly reports to Bureau of Primary Health Care (BPHC) (Rita Goodman) using the format established by the National partners. Quarterly reports are due January, April, July, and October 15. The format and reporting requirements and dates will change with the transition to the Health Disparities
  Collaborative.
• Perform Clinical Assessment Software Application (CASA) assessments at each participating site at least two times (every 6 months) during the year on both 12 and 24-month-old patients. Use the methodology adopted by the TOTs project and use common review dates of March 1 and September 1 for all sites. March 1 data will be due by June 15 and September 1 data will be due by December 15.
  When reporting CASA data, indicate total number in the cohort as well as sample size for each site. The last CASA assessment will be done Spring 2002.
• Submit team staging report 2 times a year with the CASA data, using the criteria established by the National partners.
• Provide feedback of data and recommendations to health center staff following assessments.
• Participate in all training and conference calls.
• Clearly identify health center sites that have dropped out of the project and those that have been added. (include date dropped/added)
• Participate in evaluation of the project at the national, State and local level, including submission of information to the Connecticut PCA for updating the Directory of Successful Practices.
• Assure an email and listserv communication link via Internet with the PCA and Clinical Network and each.
• immunization team at each participating site.
• Participate in training re-collaborative model on April 17, 2001 prior to the Diabetes III/Cardiovascular Collaborative kick-off.
• Attend Diabetes Mellitus (DM) III/Cardiovascular (CV) Collaborative kick-off learning session April 19-21, 2001 (Dallas, Texas) and then attend the other two learning sessions in their respective clusters. The Lead PCA will travel coordinators to the DM III/CV learning session 1 (kick-off) and to all other
  learning sessions
• During the year the BPHC will pilot test a prevention collaborative in 10 to 20 health center sites that includes the measurement of immunizations beginning October 2001. This collaborative will use the Institute of Healthcare Improvement (IHI) learning and improvement model to change and improve primary care practices through the implementation of an evidence-based care model. Coordinators will act as faculty for prevention and other designated learning sessions, under the direction of the Cluster Director. Additional responsibilities will include site visits, conference calls, participation in the cluster steering
  committee meetings and development of expertise in several of the collaboratives. The PCA must agree to participate in the pilot and remain flexible to alterations in plans as the initiative evolves. The lead cluster PCA will support travel for the pilot activities, including training.

II. The following format should be utilized for the Letter of Intent:

A. Summary of year 5 activities/accomplishments

B. Syntheses of

• Major accomplishments during the year
  • Partnerships
  • Performance improvement efforts at health centers
  • Performance improvement efforts at State level, e.g., how PCA has improved service to participating health centers and facilitated performance improvement
  • CASA assessments/reporting
• Major lessons learned during the year regarding
  • . Partnerships
  • Performance improvement efforts at health centers
  • Performance improvement efforts at State level

C. Transition Year

The mission of Together for Tots is "to guide national immunization efforts towards excellence by building both State-based and community health center systems that implement continuous quality improvement (CQI) strategies and by expanding partnerships at the local, State, and national levels." During the year, the BPHC will be transitioning to a care and improvement model consistent with other health disparities initiatives, and piloting the model in 10-20 health centers.

The TOTs mission will be aligned with the disparities collaborative with input from TOTS partners. To realize the mission, the integration of proven performance improvement strategies in immunization systems and sharing of information among partners and participating sites will continue during the transition year through:

• Use of data to improve immunization systems, including the application of CASA, provider survey data, and qualitative information on performance improvement processes, collaboration, and lessons learned.
• Identifying and spreading innovative Abreakthrough@ practices through benchmarking and networking among health centers, State and local health departments and other public and private providers.
• Strengthening collaboration and team development at the health center, State and national level.
• Leadership development for performance improvement at the health center, State and national level.
• Transition to a collaborative approach based on the IHI Breakthrough Series learning model.

With these over-arching themes in mind and priority issues identified in sections A and B, develop the transition year plan in terms of:

• Goals/objectives (measurable)
• Partnerships--State/local, public/private, internal/external
• CQI activities (identify)
  • Development and implementation of improvement strategies.
  • Networking and communication among health centers.
  • Recognition of health centers demonstrating significant improvement.
  • Preparation of quarterly reports to the BPHC (to be shared with the clusters, IHI, National Immunization Program, National Association of Community Health Centers, and the State immunization programs) on implementation issues, follow-up data, outcomes and selected process
    information. These reports are due on the 15th of the month following each quarter: January15, April 15, July 15 and October 15. As the transition occurs, reporting dates and format will change and reflect requirements of the Health Disparities collaborative.
  • Principal activities to be performed by the PCA Executive Director to engender senior leadership support in participating health centers for the transition to the health disparities collaborative.
  • The approach to be used to (1) share and interpret findings to participating centers; (2) facilitate performance improvement and team development; (3) assess progress through periodic revisits; (4) exchange information, and network among participating sites; (5) disseminate successful strategies,
    problem solve, and arrange assistance to sites as needed; and (6) facilitate senior leadership support for the immunization program at the health center and State levels.
  • Communication activities for the immunization initiative, e.g., newsletters, meetings, presentations, email and listserv.
• Timeline: 12 month schedule for .
  • CASA, Team Staging and Provider Survey assessments
  • Feedback to Community Health Centers, BPHC, clinical network.
  • Sharing data and experiences with State health department and other partners.

D. TOTs Closeout will be prior to the kick-off of the full Prevention Collaborative in 2003.

E. Budget and Justification

The Letter of Intent must include a one-page itemized budget request and justification for the period, April 1, 2001-March 31, 2002. It should describe personnel (by position, % FTE, salary, benefits), travel costs (instate and out-of-state) as appropriate, health center training, and overhead (rent, printing, supplies, telephone/fax, postage). Travel costs for collaborative workshops and training sessions will be paid by the lead PCA.

E. Other

The proposal must also include, as attachments, a written agreement or contract with the lead PCA signed by both Executive Directors, and written documentation of continuing collaboration with the State or regional clinical network or clinical committee, State Immunization Program, and other programs, such as Women, Infant and Child, Maternal Child Health, or State/local outreach activities, as appropriate.

Funding decisions will be based on:

• Documentation of collaboration with the lead cluster PCA.
• The plan for transitioning into the Health Disparities Collaborative.
• Quality of the proposed approach to demonstrating measurable improvement in immunization rates at the health center level.
• Letters of continuing support from and history of collaboration with the State Health Department immunization program and the State or regional Clinical Network or clinical committee and other major partners.
• The degree to which the PCA and Clinical Network has utilized lessons learned and other information from the quarterly reports to improve their approach. Accomplishments of the past 5 years, including development and implementation of innovative approaches to improving the quality of pre-school immunization systems at the health center and State level and median immunization coverage levels for each cohort for each of the reporting periods.
• Degree to which the PCA and Clinical Network meets program goals and expectations, including timely submission of quarterly reports, data and other information as requested.
• Commitment to participation in the training for and transition to the health
  disparities collaborative model.

Please address questions concerning this project to Rita Goodman at (301) 594-4297 or David M. Stevens at
(301) 594-4300.