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last updated: 7/26/2004; 9:21:39 PM
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Marc's Weblog
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Pursuing Perfection
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Marc's Weblog
 | Report to Boards Feb. 03; by MP |
 | Our Promises to Patients |
 | Click here |
| Story of the month. Trip to Washington DC to meet our members of Congress (click to view) |
| Read the "one pager" on the our community's work that we left with Senators Murray and Cantwell, and Representatives Larsen and McDermott |
| Recognition: |
| Dawn Gauthier  |
| Dawn's passion for improving the patient's access to information and her skill in understanding customer needs and working those needs into software is remarkable. She is a great team player too. |
| Click here to see her web site. Please look at the electronic shared care plan that she and her team have built. |
| Vision for the Grant: A New Healthcare Future in Whatcom County |
| We are focused on getting you what you ask for as a patient. |
| Your goals, values and needs are our central focus. |
| We are supporting you and your virtual care team with: |
| A secured shared care plan that communicates information you want your care team to know to better coordinate your care and support your goals |
| A shared accurate medication list to promote safety |
| Access to clinical information at all times |
| A clinical care specialist when needed to act as self-management coach and healthcare navigator |
| Across our diverse community, together with your help, we are building safety,timeliness, effectiveness, efficiency, and equality into our healthcare system. |
| How are we doing this? |
| Starting with Diabetes and Heart Failure patients |
| Starting with a few medical groups and the hospital |
| Funding by Robert Wood Johnson Foundation |
| Creating exceptional partnerships with community members who want and support a new way to deliver health services - Networking with other like minded communities in the US and Europe |
| Complex Adaptive Systems with many parts: |
| It is important to keep the concepts of complex adaptive systems in mind. |
| However, the more I understand about US heathcare, the more aware I become that incentives and inducements for "adaptation" are missing. We are mostly left with a complex system with no ability for adapataion or design. Frightening. |
| Here is a link to Paul Plsek's Appendix B from the Chasm Report. Click |
| Here is a link to the Strengths and Challenges Report from the Phase I site visit. Click |
| General Orientation: |
| Pursuing perfection is community-based care management for patients with chronic diseases. It includes: |
| Virtual Care Teams, Patient at the Center, Clinical Care Specialists (CCS), Shared Care Plan (SCP), Information 24 X 7 |
| Two chronic diseases--diabetes (DM) and congestive heart failure (CHF), multiple provider organizations, multiple payer organizations, national grant, new inter-organizational resources--Pursuing Perfection Staff |
| The second phase of the grant began in June of 2002 and is currently funded through September of 2003. We are looking for funding to take us to at least June of 2004. |
| Patients: |
| Diabetes Promises Measured--January (click to download, expect a delay) |
| Heart Failure Promises Measured--January (click to download, expect a delay) |
| 31 / 1021 Diabetes patients in pilots with CCS and SCP |
| We have just begun this program with clinical care specialists for Diabetes and Heart Failure. We don't know how many patients a CCS will serve, nor do we know the "graduation rate" to self management. |
| 23 / ~1,100 Heart Failure patients in pilots with CCS and SCP |
| Intimately involved in developing the Shared Care Plan |
| There is a paper shared care plan now. Developed over the last year with patients. |
| We are learning how to use it across sites. We are also developing an electronic equivalent that will securely keep a patient's team informed. This patient-centered record will continue to evolve, but we have a functioning version in January of 2002. |
| Intimately involved in developing the patient centered web sites. www.PatientPowered.org |
| After extensive pateint feedback on our first web designs we have begun rebuilding what they want. Here is the material for Diabetes and Congestive Heart Failure. These sites will need to change with patient needs and with developments that support patients and their families, locally and globally. |
| Signing up and being oriented to support teams improving health care |
| We have developed an intake and orientation for patients wishing to participate in the ongoing refinement of the healthcare system. |
| Access to information 24/7 |
| www.PatientPowered.org |
| Diabetes web site |
| Check out a Diabetes Online Tutorials |
| Group visits for diabetics are occuring at Ferndale Clinic and Sea Mar. St. Joseph Hospital diabetes educator, Cindy Brinn, is participating and takeing the care to the patients. |
| Prevention and screening for diabetes: About half of the benefit to the community will come from these efforts. We are just beginning to explore the issues. (Link is to an journal article on this topic.) |
| Clinics (Ferndale, Sea Mar, Senior Center, North Cascade Cardiology): |
| Touch screens for patient satisfaction surveys (includes considerable infrastructure) |
| These computers will be used to collect information from patients in near real-time so we will know how they perceive our service and the delivery on our promises. This kind of feedback for learning is likely to be an ongoing way of doing work. |
 | Guidance teams (various stages of development) |
| There is a wide spectrum of awareness and interest across clinic sites in the Pursuing Perfection approach. Teams are coming together first to understand the what and why of Pursing perfection and then they will get to the how in their clinic. |
| Work teams for idealized design of clinical office practice (IDCOP) and for implementing registries and changed processes to accomplish patient promises |
| This work consists of measurement of work flow and patient wait times and is followed by changes in work flow to support more timely care processes and more efficient clinic operations. It can result in less frustration and also in financial gains for the clinics. We anticipate this approach being made available to all clinics that participate in the other components of Pursuing Perfection during the grant and beyond if at all possible. Funding will need to be secured. |
| Team measures, organizational development (OD) support and process facilitation support |
| Hospital: |
| Operational support has been identified and a plan is being developed for designing the role of the hospital into Virtual Care Teams: SCP, CCS, Medication Hand-offs, and Patient Educational Support. Marla Sanger is taking a lead role and is supported by Judy Pratt and Martha Shepler. |
| Leadership Board: |
| Partner organizations (click for overview) |
| SJH, North Cascade Cardiology, Family Care Network, Sea Mar (local and state), Group Health Cooperative, Regence Blue Shield, Community Health Plan of Washington |
| Items getting attention: |
| Moving toward desired ability to make shared decisions |
| Clinical Care Specialist unmet need |
| Shared Care Plan available to any patient |
| HIPPA decisions |
| Heads up on shared medication list |
| Advocacy Role....Champions of Change |
| Issue of cost/impact of connection across a community |
| Prioritization of Actions Steps from retreat in context of confirmation of understanding P2 Vision, Role of PPLB re: P2 grant and beyond for true transformation |
| Robert Wood Johnson Foundation and Institute for Healthcare Improvement: |
| Visitors in November: |
| Institute of Healthcare Improvement provided a technical assistance visit by Maureen Bisognano (co-director of IHI), Polly Arango (National Advisory Committee member and nationally recognized patient advocate) and Connie Davis (GHC Chronic Illness Care Collaborative and IHI faculty). It was informative for all concerned and a very positive experience all around. |
| The film documentary team visited and began collecting material and film for a PBS documentary of the RWJF Pursuing Perfection project. |
| Boston University staff came for their second of six visits to learn, document, and grade how we are doing relative to the grant goals and to others. |
| Budget: |
| On track |
| Grants: |
| Kellogg Foundation in discussion, expect to hear in Feb. 03. |
| Others being sought by Catherine McIntyre |
| Working with Bill Mahoney, PhD on the scientific and research basis for much of our work, to make it meaningful for the nation and to align with grant funding agencies, especially the AHRQ (see link). |
| Payment Realignment: |
| Using System Dynamics Modeling and Simulation to understand our local complex adaptive system and agree on policy changes for payment to match new methods of care delivery. |
| To see a very brief explanation of System Dynamics, click here. |
| To see a different description of System Dynamics, click here. |
| To see current model runs, click here. Expect a delay. |
| Systems Dynamics Test Drive of Diabetes model, week of Oct. 28, '02 |
| System Dynamics modeling for Diabetes shows large benefits in patient outcomes at an overall lower community costs. |
| Modeling of Congestive Heart Failure has begun. |
| Model sharing meeting with Region 10 CMS (Medicare / Medicaid) and Washington State Medicaid representatives lead to agreement for data sharing and discussions on strategies that can lead to cooperation / legislation / demonstration projects that support this approach to care management and infrastructure building. |
| Advocacy: |
| Carol Boston-Fleischhauer is leading our efforts. We are parterning with Priemer to connect with folks in Washington, DC. |
| Robert Wood Johnson Foundation has arranged for three people from each Pursuing Perfection site to go to Washington, DC for three days in February and to meet with our legislators. Rebecca Bryson, John Hayward, and Marc Pierson, MD will be our representatives. The goal is to educate our representatives on innovative solutions to healht care problems and to create linkages that can further the spread and sustainabiltiy of these intitiatves. It is anticipated to be the first of onging connections with the "Hill". |
| Measurement: |
| Measurement is essential to know if our new methods are effective and help us change course as needed. |
| We have developed several valid measures that will be essential to our improvement approach. |
| Patient activation |
| It is currently being tested. We are waiting for IRB approval on testing. Once it's validated we will use it with CCS patients first and then with interested providers. Sarah Jane Satre is coordinating this validation. |
| Team development |
| Depression |
| Physical function |
| Perceived health competence |
| Patient perception of care as patient centered |
| PowerPoint presentation on our planned measurement strategies and tools. |
| Data: |
| New Heart Failure registry in place with Senior Center data entered. Moving to other clinic sites. |
| Large amounts of data are gathered and processed each month for the reports to IHI on our promises to patients with Diabetes and Heart Failure |
| Most data gathering is to measure how well we are meeting our promises to patients. |
| A matrix with the promises and the measurements expected. |
| Information Technology Team: |
| Work on electronic Shared Care Plan is progressing. Efforts to connect LastWord are ongoing. |
| We are beginning our implementation planning for the shared care plan. |
| We will have a first working version in use for a small number of patients in Nov. 2002. We will be connecting LastWord to this web-enabled patient centered communication tool. We hope that all patients with chronic conditions will get the benefit of this tool. |
| See the paper version to understand the functionality. |
| Electronic medical record selected by Family Care Network is Logician. David Lynch notified us that FCN voted to move ahead with the purchase of Logician for some intitial clinics. Plan and cost for interconnections have not been determined. Wake Forrest has LastWord and Logician. There is very little integration of the two platforms, however. |
| Imminent: |
| Increase capacity of Clinical Care Specialists intake and throughput |
| Advocacy strategy--lawmakers, medicare / medicaid, others |
| Off time line: (none are critical at this point) |
| Team development in clinical sites |
| Data acquisition process from CMS is complex, even with CMS support. |
| We have a useful WWW communication strategy that makes good our promise of transparency. One way into it is through: |
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© Copyright
2004
Marcus Pierson, MD
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Last update:
7/26/2004; 9:21:39 PM
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This theme was created for WWPP by Jack
F. Mancilla |
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