Link to Bellingham Herald Editorial

Link to more about program

Helping chronically ill manage care improves lives, cuts costs
HEALTH CARE: "Pursuing Perfection" program is so simple, it's brilliant.

The whole point of "managed care" started out, at least in theory, as an attempt to contain health-care costs through prevention. It's no secret that's not what happened. In fact, navigating the medical maze has become more difficult than ever, it seems.

But there is a solid movement afoot to change that and Whatcom County is one of the ground-zero sites for a program called "Pursuing Perfection: Raising the Bar for Healthcare Performance." Its method isn't complicated. It seeks to help people manage their own health care, sometimes by doing something as simple as regular telephone calls to check up on patients and answer their questions. By heading off potential problems, extensive and pricey hospital visits can often be avoided and a patient's health better maintained. It's so simple, it's brilliant.

The Whatcom Community Health Improvement Consortium last year was one of seven groups in the nation to win a $20.9 million grant from Robert Wood Johnson Foundation and the Institute for Healthcare Improvement that funds the program. It's not just some kind of feel-good program, either. The foundation wants to document measurable results in improvement of patients' access to care, patients' self-management and satisfaction, and a decrease in medical errors.

Caring for chronically ill people consumes as much as 70 percent of the nation's health-care dollars, so it makes sense that helping them manage their own conditions would reduce those costs and help those people lead more productive and less frustrating lives.

In Whatcom County, two of the most common chronic illnesses are diabetes and congestive heart failure. In 2000, St. Joseph Hospital had almost 700 admissions related to diabetes and almost 900 related to congestive heart failure.

Empowering patients with better information and better access to people who monitor their progress and can quickly answer questions can help keep many from becoming dangerously ill and compromising their health further. Medical advances happen quickly as new drugs are developed, more information is discovered about drug interactions and new technologies help people monitor their blood sugar. Keeping patients active in helping to make their own decisions will result in better outcomes. After all, who better to "manage" the care than the person living with the illness?

Robert Wood Johnson Foundation's CONNECT PROJECT guided meetings in Washington DC this week.  Six of the seven US pursuing perfection sites met with their congressional members.  The Whatcom county team consisted of Rebecca Bryson (patient), Marc Pierson (me, project executive), and John Hayward (CEO of PeaceHealth). We met with Senators  Patty Murray and Maria Cantwell and with Representatives Rick Larsen and Jim McDermott. The meetings were informational and well received. Each member agreed to work with us to learn more about what we are doing and to lend their support to comprehensive clinical quality improvement efforts.

There was also a meeting with the National Health Policy Forum. The subject was "Pursuing Perfection in Health Care Delivery: Insights from Innovators". There was good attendance by congressional staffers and health agency leaders. Donald Berwick, MD, led off and presented context for the briefing. Honor Page, the mother a patient with cyclic fibrosis spoke next. She gave the patient's or consumer perspective on the current status of health care as well as on her interactions with Pursuing Perfection project at Cincinnati Children's Hospital. Next was Dr. Brian Rank from HealthPartners, Bloomington, Minnesota, explaining the frustration and challenges from the perspective of a physician leader pursuing perfect care in today's environment. Finally John Hayward spoke about the need for change and his rationale for the work going on in Whatcom County, WA, as well as explaining his personal commitment to transformational change in his organization.

Rebecca, John, and I all felt like the relationship building with our congressional members is off to a good start. As you all know, for the improvement that we have started to be sustainable, both Medicare and Medicaid will need to become more flexible in matching payment to innovations in care. Our short and long term goals will be some small appropriation to help cover the short fall on our start up of this transformation, then a demonstration project that will provide the needed flexibility to this county. Ultimately the payment structure of Medicare and Medicare will need to be modified based upon the successes of the demonstration projects.

Click on this link if you would like to study most current recommendations by the Institute of Medicine to CMS (medicare/medicaid) for demonstration projects aimed an transforming health care and aligning payment. Four out of five proposed types of demonstration projects are highly aligned with what we have already begun with Pursuing Perfection and Robert Wood Johnson Foundation.

Stacey and I are strategizing the development of staff leadership skills in Ferndale, so they can take over her facilitation

Brainstormed goals for the staff retreat scheduled for Jan. 25.

Decided to develop an appreciative interview protocol addressing teamwork and team issues to begin FHA's P2 journey

Identified plan to develop the FHA Guidance Team

North Cascade Cardiology Guidance Team

1. shared baseline clinic data results from the initial surveys which included patient wait times, provider interruptions and the office staff survey.
2. Discussed strategy to bring all the doctors in this clinic on board with P2
3. Agreed to begin staff interviews utilizing an appreciative approach in preparation for all staff retreat Feb. 1

Building International Bridges

Marc and I met with Helen Lingham and Gabriele Cuff from Fraser Health System in B.C. Canada. We shared information about the Pursuing Perfection project and did some thought partnering around effective organizational development approaches in the health care system. Specifically, we shared our common interest, learnings, and plans for using appreciative inquiry in our respective systems.

What's ahead

Developing appreciative interview protocol and strategy for staff and providers at Family Health Associates and North Cascade Cardiology.

Retreat planning for both sites.

Interviews with staff at Center For Senior Health

Meeting with Bill Mahoney and deepening my understanding of the Team Development Measure

20.

Week in Review
Here's what has been on my radar screen and what I'm looking forward to:

Ferndale Clinic

This has been the identified site of the two Family Care Associate sites as the one that will undergo the transformation process first.

Team Development Measure completed and results are being analyzed. Preliminary results suggest an improvement in identification as a "team". Is this an outcome of the appreciative interviews? The process facilitators' gathering baseline metric data, or the brief presentation I gave them regarding change and transition (William Bridges)? What these interventions have in common is that they bring to life the start of this project and interjects the concept of "team" into the clinic.

On 9/25, Stacey (process facilitator) and I will meet with the Guidance committee to identify their goals for the 10/5 staff retreat. We will share information from the Baseline Metrics and the Team Development Measure as well as a proposal for issues/topics to be covered at the retreat.

North Cascade Cardiology

Appreciative interviews of leadership staff to be scheduled through October.

Team Development Measure has been administered. We'll receive results soon that will indicate specific areas to address with the group.

SeaMar clinic

Team Development Measure will be completed next week.

We will also set up the first meeting with the SeaMar Guidance Team.

Center for Senior Health

Next Guidance Committee meeting 9/30 will include information in helping staff cope with change and transition. Stacey and Terry (process facilitators) will go over baseline metric results. We will plan next steps for action and team development based upon this information and the results of the Team Development Measure.

Other work or issues on the table:

Clarify role/responsibilities of Guidance Teams

Planning retreat for Pursuing Perfection Leadership Team retreat 10/14. Marc, Mary and I will be meeting on the 25th to put finishing touches on the appreciative interview questions and the process/agenda for the retreat.

Had a conversation with Connie (Patient Care Manager) regarding coping with the loss of patients. We came up with several ideas: creating a patient memory book with their photo, names and qualities we appreciated about them; a memory wreath, with patient names; sending a card to the family signed by all staff; lighting a candle and pausing for a reflection at staff meeting.

Deliverable/Project: Shared Care Plan 

Update Summary: 
> Bulk of coding for the SCP interface done
> Security work nearly finished
> Data entry person has entered 16 SCPs
> Both CCSs registered and oriented
> Print version of SCP available
> Doctor demographic data imported from LW into person database

Tasks Scheduled Next 2 Weeks:
> Streamline registration process 
> Add instructions
> Add Confidentiality Statement pop-up
> Register docs at clinics
> Have CCSs double check data entry work
> Create test/development system (copy database and website)
> Move live site to Internet
> Auditing functionality
> Usability testing
> Implement new tabs for interface
> FDB Medication data source?
> Thorough testing and troubleshooting of the application

Coming up:
> 12/18/02: doctors and CCSs give feedback on SCP at implementation meeting 
> Week of January 6th: register a few patients to use SCP via Internet

Deliverable/Project: Shared Care Plan
Update Summary:

> Bulk of coding for the SCP interface done; should have enough in place for a data entry person to start adding existing SCP data late next week.
> Hammered out remaining issues with medications
> Registration screens nearly finished
> Progress on integrating SCP with rest of web site (conceptually)
> eSCP shown to both patients and clinicians with good feedback

Tasks Scheduled Next 2 Weeks:
> Finish building interfaces
> Some amount of testing before data entry begins
> LW data dump
> Medication entry screen
> Polish some functionality for usability (e.g. Next Steps)
> Polish look with graphic designer
> Thorough testing and troubleshooting of the application

art.  This chart will be transitioned into a SPC chart once we have enough data points to do so.  Thanks to Sarah Jane Satre of the PeaceHealth MOMS Team for her strong knowledge of SPSS and continued help with this analysis.

2)  Later this week we will begin the first analysis of the Clinic PSAT Touchscreen Survey data.  We currently have >250 completed surveys in the hopper which is a perfect amount to create the necessary anchor file.  In addition to the creation of the anchor file we will also be able to provide the clinics with actual PSAT scores.  With the feedback gathered from the most recent Implementation meeting we will hope to reformat the clinic specific PSAT report into a more user friendly manner.  The PeaceHealth Survey Subteam of Aaron Ignac, Sarah Jane and of course Bill Mahoney will be instrumental in making this analysis a reality.

3) Began work on the Systems Dynamics data pull for Congestive Heart Failure.  This has proven to be a bit confusing and more complex than the Diabetes data pull.  At the very least it looks like an impressive challenge that we look forward to tackling.

One of the main challenges is staying in compliance with the patient confidentiality rules and regs, especially the new HIPAA regs that go into effect April 2003.  While all of us truly have patients at the center and have an enormously high regard for patient confidentiality the new HIPAA regs are creating some challenges not previously experienced.  Simply relying on our self judgment of what is "reasonable" doesn't cut it anymore.  The HIPAA regs are very specific and have teeth.  Violating these regs, even inadvertently, could sink our efforts, on a personal level as well as community level.

The first step of the Systems Dynamics pull is fairly straight forward and we should be able to submit "Phase I" data to the consultants in the very near future.  The phase I data does not involve the release or sharing of any pt identified data so we will be able to move quickly on completing this request.

Many thanks to Dori Robart from SJH and Sarah Donelson of the MOMS Team for providing their continued support and guidance with the security and confidentiality rules and regs.

4)  We created a database to assist us in tracking the rate of completion of the clinic PSAT survey.  This has proved useful in providing the clinics with immediate (daily) feedback on the # of surveys completed at their offices.  Run charts are faxed or emailed to each pilot site on a weekly and/or daily basis depending on their preference.

5)  Data collection for the measure: 3rd Next Available Appt was conducted and completed.  This is the second month of data collection for this measure.  The processes, established last month, created a very useful and efficient template for this month's data collection.  We hit a few barriers with contact folks being out of the office but in each instance the specific clinics responded positively and quickly to getting the issues resolved and helping us complete the data collection.  A big thanks to all of the pilot sites!!

Wiring/hardware installation for computer touch screen patient satisfaction survey -done.

2. Basic Metric Data Collection - done.

3. Team Development Survey - done .

4. Training for Clinical staff for Diabetes Registry - done.

5. 273 diabetic patients have been identified and accounts set-up in Last Word for implementation of the Diabetes Registry. Thanks Tracey!

6. Spanish translation for patient satisfaction touch screen survey -done. Thanks Wendy and Norma!

7. Focus Group for Spanish Diabetic Patients in regards to group visits, email access, and phone consultation/follow-up-

Thanks Jennifer!

8. Clinical Snap-shot completed in preparation for Diabetic registry - done.

9. Patient Satisfaction Survey - computer touch screen "LIVE" as of 10/28/02. This will be an on-going process everyday..........

Upcoming Meetings/ Events:

1. Daily random patient selection for Patient Satisfaction Survey - computer touch screen.

2. Friday November 8, 2002 9-9:30 am (Jackie, Lyly, Terry) meeting to discuss process for patient satisfaction computer touch screen

survey; meeting 9:30-11:00 am ( Jackie, Terry, Jean Marie) to discuss implementation of Diabetic registry.

3.Next Guidance Team meeting on Wednesday 11/13/02 12 noon - 3 pm @ SeaMar

( Dr. Adams,Jackie Coggins, Lyly Cummins, Terry, Mary, Cindy, Mary Bartolo ( via phone) ).

4. Next Implementation Team Meeting Wednesday 11/13/02 7-10 am @ FHA ( Dr. Adams) .

Terry Wagner RN BSN

Process Facilitator

Whatcom County Pursuing Perfection Project

twagner@peacehealth.org

Cell # 360 319-9786

• Continiuing prepartion on scoping of the implementation for the hospital project.
• Marla Sanger, the new AVP will be the process owner for the hospital project and the Cindie Becker will be the sponsor.
• Met with Marla Sanger and Judy Pratt twice in the past two weeks discussing a number of potential changes that could be done in the inpatient environment. Also discussing different strategies to on how to do the work involved.  Getting feedback about membership of the implementation team vs. the hospital guidance team.
• The decision was made to combine the team for both inpatient units, vs. two separate teams.
• We are developing a spreadsheet identifying all of these change items that could be considered, identifying measurements, barriers, questions, and possible infrastructure needs to bring forth these changes. 
• Will have a meeting with Cindie Becker in the next week to begin these discussions regarding areas for change.  Our sense is that we would need to prioritize these items and do them over different stages.
• We will be meeting with Carol Boston this week to have a discussion about how the potential implementation changes will interface with other hospital initiatives.  We want to build a direct link with creating healing and compassionate care.
• Aniticpate finalizing the Project Charter in the next two weeks, and then preparing for the first kick-off meeting for the Hospital guidance team and Implementation team.
• Spoke with 3 different health care organizations this past week about how they are provding care for inpatients with CHF.
• Had phone interview with Ron Stock from the Senior Health Center with Sacred Heart in Eugene, Oregon.  Discussed what he found most important in the clinic changes they have accomplished.
• Two key recommendations are improving flow in the workplace and focus on team development.
• Reading a new publication about "Magnet Hospitals" and how to create a healthier work environment
• Reviewing articles about use of clinical pathways in hospitals, including the DM guidelines from the International Diabetes center.
• Reviewing more articles about extended care pathways presented by the National Chronic Care Consortium
• Did 3 presentations about the grant with the Med-Surg and Float unit staff at their staff meetings on 11-6.  Generally, staff were receptive and agreed that management of chronically ill patients was not working well