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Section
III. PATIENT REDESIGN COLLABORATIVE |
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
-
Identification and management of Cluster-Specific
Applicant Review Panel in cooperation with
Cluster Collaboratives Steering Committee.
- Formation
and support of the Cluster-Specific Redesign
Expert Team for each collaborative in conjunction
with National Redesign Expert Team.
-
Coordination, planning and implementation
of learning sessions in conjunction with National
Redesign Expert Team.
-
Documentation of learning session evaluations
and results.
- In
collaboration with the National Redesign Expert
Team, development of strategy and ongoing
support and spread of redesign efforts.
-
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:
-
Announce the transition of the Together for
Tots (TOTs) program to the Health Disparities
Collaborative format during fiscal year (FY)
2001 - 2002;
- Inform
the Primary Care Association (PCAs) and clinical
network communities that for FY 2001 the immunization
program will continue to be funded directly.
-
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;
- Outline
program requirements for participation in
the transition year;
- Outline
the format to be used in preparing the Letter
of Intent to participate; and
-
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.
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