DRVS: UDS Colorectal Cancer Screening Quality Improvement Initiative September 17, 2015.

DRVS: UDS Colorectal Cancer Screening Quality Improvement Initiative

September 17,

2015

Quality Initiative Framework

• Pilot Six Federally Qualified Health Centers Four urban, two rural FQHCs UDS measure

• Selection Process Applicants Criteria Interest Capability

• Four EMRs: NextGen, Epic, Athena, Centricity

Project Structure

• Learning community Monthly virtual learning sessions: 90 minutes Agreement to share un-blinded aggregated data Peer-peer sharing DRVS and non-DRVS centers

• QI coach in-person and virtual meetings Monthly reports looking at trailing year and

recent months UDS data o Site and provider level

Encourage use of registries in QI setting Utilize patient visit planning reports

Project Milestones

• Six month modular format: Kick off Process mapping Sett the aim and select targets Develop an improvement strategy and start

tests of change Pilot reliable standard process of care Implement new standard process Spread new standard process

Resource Commitments

Executive Sponsor

2 hours

Leadership level sponsor

of project

Sign off upon project

completion

Project Team Lead

20 hours

Champion of QI Project

CHC resource

coordinator

Escalation point for

issues/risks

Network Admin/IT

2 hours

Provide access to

CHC Network/

EHR

DRVS connectivity

and performance

support

EHR Expert

16 hours

Review current state and

identify missing data

Workflow mapping

Participate in PDSA cycle

Participate in learning

community

QI Specialist

16 hours

Identify process measure

Complete workflow mapping

Execute PDSA cycles

Document results

Participate in learning

community

Provider Rep/Clinical

Support

8 hours

Identify data capture

workflow

Design and execute

PDSA cycles

Participate in learning

community

Colorectal Cancer Screening CrosswalkJuly 2015

Footnotes *2014 Mass average is MLCHC reported as 2014 UDS data not yet available through HRSA. **TY = Trailing year to date for DRVS data

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Colorectal Cancer Screening (2013UDS)

Colorectal Cancer Screening (2014UDS)

Colorectal Cancer Screening (2013DRVS)

Colorectal Cancer Screening (2014DRVS)

Colorectal Cancer Screening (TY**June 2014-June 2015 DRVS)

Participant Health CenterColorectal Cancer Screening

HOLYOKE HEALTH CENTER 2014 Mass average (UDS)* 2013 Mass average (UDS)

2013 National average (UDS) National HEDIS Healthy People 2020

UDS Averages Benchmarks Colorectal Cancer Screening (2013 UDS)

Colorectal Cancer Screening (2014 UDS)

Colorectal Cancer Screening (2013 DRVS)

Colorectal Cancer Screening (2014 DRVS)

Colorectal Cancer Screening (TY** June 2014-June 2015 DRVS)

2014 Mass average (UDS)*

2013 Mass average (UDS)

2013 National average (UDS)

National HEDIS

Healthy People 2020

Participant HEALTH CENTER 46.9% 48.6% 32.6% 64.0% 70.5% 54.3% 43.0% 44.0% 52.0% 51.0%

DRVS Comparison Report

Clinical Registry

Data Management & Daily Practice

Tools, Templates, and Resources

Examples of recommended tools, templates and resources:» Developing an AIM Statement» Quality Improvement Project – Implementation

Guidance» PDSA Model for Improvement & PDSA Example» Improvement Project Planning Form» A3 Instructions & A3 Blank Template» Cause & Effect Diagram» PDSA Planning Worksheet» PDSA Testing For Change» Project Charter Instructions & Blank Worksheet» Prioritization/Ranking Variation» Elevator Speech» Stakeholder Analysis & Resistance Tool» Action Plan (WWW)» Communication Plan» Developing a Storyboard

Change is hard

• Importance of senior leadership and other stakeholder support

• What do you do with the registries?• Work flow mapping• QI structure• AIM statement tool • PDSA cycles• Who has responsibility for new processes?• Project versus work sustainable change

mentality

Recommended Resources

www.ihi.org Institute for Healthcare Improvement

DRVS Learning Series: Maximize use of Visit Planning Report DRVS Training: Setting Measure Targets Baltimore Medical System/Azara DRVS presentation at NACHC CHI 2014

Azara YouTube Channel

Integrated Work Solutions QI Forum

Questions & Next Steps?

Diana EraniDirector of HCCN

[email protected]

Jennifer KincaidProject Coordinator

[email protected]