Quality In an Age of New Health Care Models - NACHC

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“Quality Management (QM)” Webinar Series

© 2013 - NACHC

Training for New Health Center Employees & A Refresher for Experienced Staff

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“Quality Management (QM)” Webinar Series

© 2013 - NACHC

Welcome back… This is the third – and final – presentation in the special series of three webinars on Quality Management (or “QM”) from the National Association of Community Health Centers. In the first two webinars, we covered the fundamentals of quality, how to structure a quality program, and how to develop a Quality Management Plan that formally documents the main features of a health center’s approach to ongoing improvement. In this final installment, we’ll address how your health center can create a “plug-and-play” template for measuring selected metrics based in patient-centered care, and we’ll delve into the related initiative driving much creative activity in health care today, the Patient Centered Medical Home (or PCMH) care model.

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“Quality Management (QM)” Webinar Series

© 2013 - NACHC

As in our two preceding webinars, we’ll begin this webinar with a touchstone quote from Dr. John Krueger, whose article “The Patient Will See You Now” was published in the Journal of Participatory Medicine. As Dr. Krueger suggests, the agenda for quality health care needs to be driven by the patient. This is the concept behind the PCMH care model. And, as with the other major initiatives with which health centers are seemingly being bombarded, the foundation of the Patient Centered Medical Home is quality. So Quality Management as a formal discipline is becoming ever more critical.

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“Quality Management (QM)” Webinar Series

© 2013 - NACHC

Let’s first put our current quality environment into a historical context. Here’s a succinct timeline of quality-related activities and perspectives from the point of view of HRSA and NACHC. These initiatives have been moving forward for decades. Each successive wave of activity has pushed the quality dial higher. Clearly HRSA and NACHC are strongly committed to continually improving quality in health centers.

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“Quality Management (QM)” Webinar Series

© 2013 - NACHC

In our first webinar, we promised to return to the poem “The Ambulance Down in the Valley”, written many years ago. It holds some interesting ideas about quality as it has developed over the years, and as it moves forward into the future. Recall that near a town, there was a cliff that was lovely to walk along, but over which many unlucky townspeople had fallen. The citizens debated and debated on what to do. Some argued for an ambulance to catch people who fell. Others, perhaps more enlightened in the ways of quality, suggested instead a fence at the top of the cliff to keep people from falling in the first place.

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“Quality Management (QM)” Webinar Series

© 2013 - NACHC

An analysis of this poem was recently made by a team interested in quality. They ultimately decided that there was perhaps a third option for the townspeople. The team points out that the ambulance essentially represents older quality thinking – “corrective action”, in which problems are routinely addressed after the fact. Alternatively, the fence is where many quality practitioners have moved in the fairly recent past – attempting to avoid problems in existing processes and systems. The team then proposes the third possibility, one not contemplated in the poem – preemptively redesigning the cliff itself so that dangerous falls simply can’t occur. This is ideally where we all want to go; redesigning our underlying philosophy and structures around the Patient Centered Medical Home model is a major step forward.

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“Quality Management (QM)” Webinar Series

© 2013 - NACHC

In the first two webinars, we referenced the national “Triple Aim” proposed by the Institute for Healthcare Improvement (IHI). NACHC has taken the Triple Aim and broken it into component parts with specific meaning for health centers. In so doing, NACHC has slightly modified the original terminology of the Triple Aims themselves, although the ultimate meaning of each Aim remains the same. A key for us is that it all focuses and interconnects through the Patient Centered Medical Home, which also serves as the binding agent for the Quality Management template we will develop in this final webinar. - NACHC’s “Population Health” equates to the Triple Aim’s “health of a defined population”. The important thing is to know the characteristics and needs of defined patient populations you’re addressing, then to meet those needs in ways that best suit the patients. A critical component is capacity building to best serve our communities. - NACHC’s “Engagement” parallels the Triple Aim’s “experience of care”. A key component for NACHC is “advocacy”, enabling health center patients to be actively involved in helping shape their own care by working – within their communities and nationally – to advance the health center model and expand its reach. - NACHC’s “Value” addresses the Triple Aim’s objective of reducing the per capita cost of care while simultaneously improving quality. A key element is “transformation”, enabling health centers to optimize both effectiveness and efficiency. Created and Presented by: Ambulatory Innovations, Inc. 7

“Quality Management (QM)” Webinar Series

© 2013 - NACHC

Since it’s central to this webinar, a brief overview of the Patient Centered Medical Home model is in order. The basic idea has been around for some time, and PCMH is now getting perhaps the most attention of any single current health care initiative. Later we’ll discuss PCMH issues in some detail; for now, we’ll just identify what the model is. Simply put, it’s a way to codify principles that put the patient and his or her family at the center of the health care experience. Dr. Donald Berwick’s three fundamental maxims, shown here, provide an excellent starting point for thinking about this care model. From the provider’s perspective, the patient and his or her welfare must be the absolute focus during every episode of care; patients themselves must feel truly engaged in the process of their own care and their resulting health status. All this presumes a real, positive, and ongoing relationship between provider and patient. By addressing care in this way, these principles ultimately deal in both increased quality and reduced costs of care.

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“Quality Management (QM)” Webinar Series

© 2013 - NACHC

Numerous national organizations are involved in promoting this new model, including:  The Centers for Medicare and Medicaid Services  The Agency for Healthcare Research and Quality  The Picker Institute  The Joint Commission  The Accreditation Association for Ambulatory Health Care (or “AAAHC”)  The National Committee for Quality Assurance (“NCQA”)  URAC  NACHC  And others. This health care model goes by a number of names, all meaning fundamentally the same thing. Some of the most common are: • Patient Centered Medical Home, or “PCMH” (the terms we’ll be using) • Primary Care Medical Home • Advanced Primary Care • Healthcare Home • Medical Home • Patient-Centered Medical / Health Care Home

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“Quality Management (QM)” Webinar Series

© 2013 - NACHC

Financial incentives are increasingly reinforcing implementation of the PCMH model. Health centers with active PCMH programs will be eligible for increased reimbursement through existing and developing programs at multiple levels, in both the public and private spheres. We’ll come back to the Patient Centered Medical Home in more detail later.

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“Quality Management (QM)” Webinar Series

© 2013 - NACHC

A related initiative we hear about frequently is “Practice Transformation”. There’s nothing magic about this concept – it’s essentially formalized improvement activity integrated with PCMH principles. - A fundamental premise of the PCMH model - and thus a clear candidate for Practice Transformation activity based in Quality Management principles - is that the patient sees the same primary care provider team as much as possible, with care being both evidence-based and fully coordinated. - Another fundamental feature of PCMH that can be supported by Practice Transformation is optimal access to care via excellent scheduling and patient flow systems. Process improvement – one of Quality Management’s techniques – clearly comes into play here. As a result of improvements in quality, Practice Transformation ultimately involves optimizing cost savings and maximizing revenues. The confluence of these issues is, of course, what Quality Management is all about.

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“Quality Management (QM)” Webinar Series

© 2013 - NACHC

So “Practice Transformation” is essentially a quality-based activity that supports the development of the Patient-Centered care model.

The Safety Net Medical Home Initiative – a partnership between Qualis Health, The Commonwealth Fund, and the MacColl Center for Health Care Innovation – informed the development of what are termed “Change Concepts for Practice Transformation”, defined as: “ General ideas used to simulate specific, actionable steps that lead to improvement.” These eight Change Concepts are grouped broadly as follows: • Laying the Foundation, including: 1. Engaged Leadership, and 2. Quality Improvement Strategy

• Building Relationships, involving: 3. Empanelment, and 4. Continuous, Team-based Relationships • Changing Care Delivery, addressing: 5. Patient-centered Interactions, and 6. Organized, Evidence-based Care • Reducing Barriers to Care, to include: 7. Enhancing Access, and 8. Care Coordination

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“Quality Management (QM)” Webinar Series

© 2013 - NACHC

Another related initiative is Meaningful Use, a major Health Information Technology (HIT) program. The term came from the American Reinvestment and Recovery Act (or “Stimulus Bill”). Its purpose is to move Health IT forward as rapidly as possible, largely through nationwide adoption of EHRs, or Electronic Health Records. While use of IT in health care goes back many years, its practical application has lagged behind other industries. The national goal is now full adoption of HIT by 2015. Financial penalties will accrue to providers who don’t meet the goals. For example, Medicare reimbursements could be reduced. Conversely, providers who successfully implement Meaningful Use milestones are eligible for financial bonuses. HIT capabilities will become increasingly important as Accountable Care Organizations – which provide financial incentives for reducing costs and improving quality – move to the forefront.

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“Quality Management (QM)” Webinar Series

© 2013 - NACHC

HIT focuses on improving care through increased use of evidence-based guidelines and decreased need to repeat important health care information. Internally, EHRs make patient clinical information instantly available to the patient’s entire care team. Externally, Health Information Exchanges are increasingly enabling instantaneous communication among multiple providers, and between multiple levels of care – thus making care coordination more effective.

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“Quality Management (QM)” Webinar Series

© 2013 - NACHC

The Health Information Management Systems Society – the professional organization for HIT practitioners – has defined five “Categories” propelling Meaningful Use, shown here. Clearly, they flow from basic health care quality concepts and reinforce the precepts of the Patient Centered Medical Home model.

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“Quality Management (QM)” Webinar Series

© 2013 - NACHC

Accreditation is another major initiative facing health centers. Accreditation by national organizations is strongly recommended for health centers by HRSA and BPHC, to promote and certify quality of care. The two organizations with HRSA accreditation arrangements are: - The Joint Commission (“TJC”) – formerly the Joint Commission on Accreditation of Healthcare Organizations, or JCHAO. - The Accreditation Association for Ambulatory Health Care (“AAAHC”) Both The Joint Commission and AAAHC are supported by the HRSA Accreditation Initiative, through which the costs of comprehensive 3-year accreditation is paid for through HRSA. Many health centers are currently accredited under this initiative. A key feature of this initiative is that health centers gaining accreditation are considered to have simultaneously met the health center Program Expectations of the Bureau of Primary Health Care. Quality Assessment and Improvement are fundamental requirements of accreditation, via specific standards of both The Joint Commission and AAAHC.

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“Quality Management (QM)” Webinar Series

© 2013 - NACHC

Both The Joint Commission and AAAHC offer, as an integral part of their accreditation processes, an option for adding PCMH recognition. Here again, costs for health centers are borne by HRSA. NCQA has a separate stand-alone program for PCMH recognition of health centers. HRSA pays for health centers to become recognized as Patient Centered Medical Homes through this program. In addition, PCMH recognition is provided by some states. For each of these avenues, Quality Management is a critical factor.

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“Quality Management (QM)” Webinar Series

© 2013 - NACHC

Another related initiative is Patient Safety. In 1999, the Institute of Medicine published a major report entitled To Err is Human, stating that up to 98,000 deaths and up to 1 million cases of harm could be attributed each year to medical errors. The primary underlying cause was identified as the fragmented nature of the American health care system. Since its National Summit in 2000, HHS’ Agency for Healthcare Research and Quality (“AHRQ”) has been closely involved with patient safety, primarily by: - Developing an evidence base for best practices, - Designing useful tools and strategies, and - Disseminating information. AHRQ’s primary concern is hospital-based safety. In the outpatient world, the leading cause of patient harm is misdiagnosis. But other patient safety issues also exist, especially in facilities performing significant procedures. Safety of patients and their families is clearly an important issue for Quality Management.

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“Quality Management (QM)” Webinar Series

© 2013 - NACHC

As part of their respective programs, the primary ambulatory care accrediting bodies all provide standards related to patient safety. Since 1993, The Joint Commission has led a dedicated National Patient Safety Goals program. These Goals include items directly related to the Ambulatory Health Care Accreditation Program.

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Risk Management – closely linked with both patient safety and the Federal Tort Claims Act (“FTCA”) – is both a health center Program Expectation and a requirement for accreditation. Whereas patient safety focuses largely on individuals, Risk Management is essentially an organizational construct. HRSA provides numerous resources for meeting Risk Management requirements. Many are web-based, produced largely in partnership with ECRI Institute.

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© 2013 - NACHC

So Risk Management as a specific functional activity is clearly a necessary part of comprehensive Quality Management. However, as we saw in the previous webinar, it is usually not necessary to put all details of your Risk Management program into the health center’s Quality Management Plan. While, if desired, Risk Management could be a subsidiary section within a Quality Management Plan, it’s generally enough to simply cross-reference this program in the QM Plan – thus making the Plan simpler and shorter.

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“Quality Management (QM)” Webinar Series

© 2013 - NACHC

Another important quality-related national initiative is the Federal Tort Claims Act, referenced earlier. Under FTCA, specified individuals within health centers are considered Federal employees, and are thus covered for malpractice at no cost. Judgments are paid via funding channeled from annual health center appropriations. The primary focus of this initiative is health center claims management and optimized patient safety via formal Risk Management and Quality Management programs. Annual “deeming” applications to HRSA must contain detailed information regarding Quality Management, Risk Management, and Credentialing / Privileging. For example: - The Quality Management Plan must show Board approval within the prior 3 years; - Formal systems must effectively monitor risk; - Ongoing Quality Management activity must be documented; and - Credentialing / Privileging for providers must be done every 2 years.

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“Quality Management (QM)” Webinar Series

© 2013 - NACHC

As a major force in originally obtaining eligibility for FTCA coverage by health center employees, NACHC is vitally interested in ensuring the success of this important qualityrelated program. Thus, NACHC collaborates with HRSA and BPHC to offer continuing help and support in a number of ways to health centers needing FTCA assistance.

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“Quality Management (QM)” Webinar Series

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As you know, each of our webinars has included a “special focus” section highlighting a critical area to which health centers must pay especially close attention. For our final webinar, we have chosen as our special focus the specific care model that health centers are increasingly being asked to implement – as we’ve noted several times, it’s the Patient Centered Medical Home.

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The PCMH model is fast becoming the clinical gold standard in today’s health care environment. While the fundamentals have been around for some time, they have only fairly recently coalesced. With increasingly widespread adoption, it appears that the PCMH model has a good chance of accomplishing its main objectives, which include: - Advancing health care quality consistent with the Triple Aim by actively promoting both improvements in care and cost reductions (partly through better resource utilization). - Reducing ER visits and hospital admissions through more personalized quality at the primary care level, as well as better care coordination and information sharing. - Making the most efficient use of a vital resource – the primary care physician – by actively employing sophisticated team-based care mechanisms and enhanced access and scheduling systems. - Bringing increased attention to – as well as funding and reimbursement for – both quality-based systems and the PCMH model itself.

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© 2013 - NACHC

Depending on the state of a health center going in, transition to a true PCMH model is not necessarily easy or quick. It will affect many aspects of a primary care practice. - Roles and responsibilities of many of the people in the organization may well change. Actively pursuing a true team-based approach, for instance, can change relationships among providers and support staff. And the Quality Management structure places specific accountabilities on both key staff members and front-line associates, potentially changing those relationships. - As Quality Management takes hold, improving processes will become a way of life. Measurement will become the norm, and improvement teams will be commonplace. - Increasing use of Health Information Technology will go hand-inhand with improved quality of care. Communication will improve among providers, and – because the process is “patient-centered” – patients themselves will be brought into the electronic communications loop.

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As we have seen, patient-centered care is not new; the basics go back a number of years. In the 1900’s, Ian McWhinney, a Canadian physician, became known as the “Father of Family Medicine” for his work in promoting a broad-based approach to primary care. At around the same time, George Engle – an American psychiatrist – promoted a “biopsychosocial” model of care that brought multiple non-medical factors into play. Both of these men were ultimately putting the patient and his or her experience of illness at the center of care, creating a partnership between patient and provider. At the time, this was not the way health care professionals generally thought. In the mid-1960s, the American Academy of Pediatrics began promoting the idea of a “medical home” for centralization of medical records (and thus, effectively, care) for special needs children. With this foundation, the AAP in 2002 created a set of operational characteristics for a medical home, mandating care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective.

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Picker Institute is known as an important player in the measurement of patient experience with an emphasis on patient-centered principles. In the belief that existing data tools were almost solely institution-driven, in 1987 Picker undertook a project – in partnership with Harvard Medical School and The Commonwealth Fund – to identify markers of care from the viewpoint of patients and their families. The study involved six years of intensive research, including focus groups with health care professionals and consumers of health care services.

The results were tracked in an important book entitled Through the Patient’s Eyes, published by Jossey-Bass Publishers and still available today.

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The study resulted in Picker Institute’s creation of specific principles of patient-centered care, which are still promoted by this organization. The eight Picker principles are shown here.

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Today, of course, many organizations actively promote patient-centered care. As we saw earlier, these organizations use a number of different names to describe their models. Some of the main players – public and private – who are active in the promotion of this model are shown here. We will briefly look at a few of these, as examples of what’s currently out there. It will soon become clear that no matter what the organization or the specific wording of the principles, the PCMH model addresses basic common elements.

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Of special interest to us, of course, is what HRSA thinks about the model. Here are six factors that HRSA terms “Domains”, which together define a Patient Centered Medical Home. For its PCMH recognition program, The Joint Commission essentially maps its five main PCMH operational characteristics to HRSA’s six Domains.

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© 2013 - NACHC

Our next example is shown primarily because of the power of the promoting consortium and its influence in nationwide development of the generic patient-centered model. You can see these “joint principles” referenced in multiple contexts by numerous organizations, and they form the basis for the work of the important Patient Centered Primary Care Collaborative that includes health care professionals, business leaders, and others. They also underlie NCQA’s PCMH recognition program. In 2007, the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association came together to blend their patient-centered ideas into one unifying document. The collaborative group agreed on seven fundamental principles, shown here and on the following slide.

These should begin to look pretty familiar.

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© 2013 - NACHC

Here, too, of course, Quality Management is at the heart of these “joint principles”.

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As we’ll see in more detail shortly, the three main organizations providing PCMH recognition for health centers are: - NCQA - The Joint Commission, and - AAAHC NCQA’s patient-centered philosophy is largely based on the “7 Joint Principles” we just saw (from the collaboration of professional medical societies). NCQA’s resulting standards are shown here.

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The Joint Commission’s PCMH concept addresses five operational characteristics, shown here. As we’ve seen, they’re intended to “map” to the six HRSA Domains for PCMH.

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AAAHC’s Medical Home philosophy is based on six practice characteristics, shown here.

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We need to spend a little more time with the specifics of actual PCMH recognition for health centers. With the ascendance of the PCMH model, it was perhaps inevitable that ways would be sought to officially recognize successful efforts to transform our practices into effective Medical Homes. HRSA was an early adopter of this idea, given its successful history with the health center Accreditation Initiative. HRSA’s PCMH Initiative includes a special program through which health centers can attain recognition through the National Committee on Quality Assurance (NCQA). Costs of the program are borne by HRSA. Note that this is not a full accreditation program for health centers, since NCQA accredits only health plans. Health Centers can, of course, continue to pursue comprehensive ambulatory care accreditation through The Joint Commission or AAAHC, with application / survey costs being paid by HRSA. And with both of these accrediting bodies, health centers can now pursue special “add-on” PCMH recognition as part of the regular accreditation process, at no cost to the health center, courtesy of HRSA.

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NCQA’s program for PCMH recognition is called the Physician Practice Connections – Patient Centered Medical Home Recognition Program. As noted, it’s a stand-alone recognition, good for three years. The program offers three Levels of PCMH recognition, based on a survey point total and the ability of a health center to meet 10 “must-pass” mandatory performance elements.

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As an alternative to stand-alone NCQA recognition as PCMHs, health centers can instead pursue “add-on” PCMH recognition as part of The Joint Commission’s Ambulatory Care Accreditation program. If successful, the health center will receive both regular accreditation and additional designation as a “Primary Care Medical Home” (The Joint Commission’s “brand name” for the PCMH model). Many already-existing Elements of Performance (or EPs) that form the basis for TJC’s ambulatory care accreditation survey also relate to the PCMH model. In addition, TJC’s Designation process adds new EPs addressing specific PCMH requirements. Hand-in-hand with accreditation, The Joint Commission’s PCMH Designation is good for a 3year period.

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AAAHC also offers add-on PCMH recognition for health centers, to accompany regular AAAHC accreditation through HRSA’s Accreditation Initiative.

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While there are a number of parallels between the TJC or AAAHC add-on PCMH recognition programs and HRSA’s stand-alone recognition initiative through NCQA, there are also some important differences, as well. These are shown here.

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Given the various organizations and related standards health centers can choose from for PCMH recognition, a guide is sorely needed to compare these organizations and their requirements. Thankfully, three excellent comparison tools are available at no charge from, respectively, HRSA (through the Bureau of Primary Health Care), the Urban Institute, and the Medical Group Management Association (MGMA). In addition, an educational resource for how to become a PCMH – entitled the “Medical Home Builder” – is available for a fee from the American College of Physicians.

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A useful component of the comparison tool from the Urban Institute is an analysis of the most-emphasized PCMH issues across the spectrum of accrediting bodies. One interesting finding stands out: - The three most important generic issues among these accrediting bodies in aggregate were, in order of criticality: Care Coordination, Health Information Technology, and Quality Measurement. All of these issues, of course, are addressed by a health center’s Quality Management program.

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Before leaving the issue of PCMH recognition, we should note that recently another accrediting body entered this arena. Although it has no official sanction from HRSA, the PCHCH Practice Achievement Program from URAC is also available to health centers; centers must, however, pay for participation. URAC’s PCMH program, like that of NCQA, is a stand-alone recognition. It is based in the “7 Joint Principles” we’ve seen previously. Successful PCMH applicants receive either “Achievement” status, or recognition as “Achievement with EHR” (which signals successful adherence to Meaningful Use guidelines).

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To sum it all up, for our purposes here the most important thing is to understand that Quality Management is key to all PCMH models and among all PCMH recognition programs. Thus, developing a truly functional Quality Management Plan and related Quality Management program is of major importance to health centers hoping to catch the PCMH wave.

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As usual, we are providing several exercises for you to address when time is available, either on your own or with your quality team. Here’s the first one in this webinar…

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Before leaving our discussion of the Patient Centered Medical Home, we want to briefly note some special sources of help for health centers wanting assistance in moving toward the PCMH model. - At the national level, NACHC offers help through its PCMH Institute (or “PCMHI”). - A primary state-level resource specifically for health centers is the Primary Care Association located within each state. Of special importance within these organizations is the designated “PCMH Coach”.

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Please feel free to send any questions you may have about these resources – or about the PCMH model itself – to NACHC’s PCMH Institute, at the email address shown here.

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Let’s now step back a pace or two and take a quick look at what the rapidly-advancing PCMH model promises, on both the upside and the downside. Depending on where it’s starting from, a health center could find that transitioning successfully to a PCMH model creates some initial heartburn. Since the model is complex and has a number of moving parts, transitioning to it is not necessarily easy. For instance, a health center could see productivity initially decrease as enhanced HIT is implemented, processes are changed, and existing roles and relationships morph into new ones. This, however, will be a temporary phenomenon. Because of the fundamental changes that may be required, time will likely become an increasingly precious resource in the short term. In addition, money will likely be needed to enable the full transition, to pay for more robust HIT capabilities, the costs of added hours / staff, and so forth. But be assured that from many perspectives, the payoff will be well worth all the effort…

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For the health care system as a whole, evidence is mounting that successful implementation of the PCMH model is in fact beginning to show both improvements in care and reductions in cost. The Triple Aim is beginning to be met.

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A study at University of California / Davis found that an important outcome measure is also showing very promising results. It reported that the use of PCMH concepts in studied organizations resulted in reductions in the risk of patient mortality. An important issue for health centers is job satisfaction. URAC has reported, in a study involving 65 safety net providers in five states, that a strong correlation was found between PCMH principles and higher morale / job satisfaction. Finally, although clearly the landscape is ever-shifting, the PCMH model is increasingly being seen as a way for health care providers to maximize revenues. New PCMH-based payment structures are beginning to emerge. And PCMH concepts underlie the evolving Accountable Care Organization (ACO) model, which promises financial reward for excellence in care delivery and cost reduction.

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We now leave our “special focus” to return to the Quality Management model itself. We promised you that we would provide a template that would help your health center on its journey to ongoing improvement. Here’s where we make good on that promise.

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What we need is a standardized template that will accommodate the requirements of virtually any programmatic initiative; be consistent with the precepts of the PCMH model; and enable a health center to continually address important quality objectives. Of course, any such template must also generate constant progress toward the national Triple Aim.

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To create such a Template, we began with the idea of “Quality Categories”. These are broad conceptual areas that relate directly to major PCMH principles, addressing both primary care needs and issues relating to specific initiatives and populations. We have created eight such broad Categories. They underlie development of the next level of specificity – the programmatic “Metric Paks” that encompass functional collections of program-specific metrics. The measurement of these metrics will ultimately drive ongoing assessment and improvement.

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We created this structure to enable health centers to consistently address Quality Management within both existing clinical and administrative programs (including general primary care as practiced by health centers since their inception), and new initiatives that continually enter the health center arena. As you’ll recall from our discussion on Quality Management program structure, it’s possible in mid-sized-to-large health centers to create Quality Committees for separate complex programs, such as HIV, Behavioral Health, Dental, School Health, etc. Each of these Committees can use the Template displayed here to address its specific program or initiative.

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Each Quality Category contains two complementary parts: - A definition of the Category itself - A list of important health system concepts underlying that Category Note that our list of broad Categories includes one focused on quality of business processes. Such processes are, of course, vital to a health center in that they both enable ongoing financial health for the organization, and provide for continuing or expanding care provision by keeping the doors open and ensuring that “the trains run on time.” Within the construct of our overall Quality Management program, the objective is to ensure that in each Category contained within every program or initiative, there is at least one measurable metric that will enable ongoing Quality Management. It’s important to understand that to start, you don’t need numerous metrics in each Category for every program – that road can easily lead to burnout and ultimate disenchantment with the Quality Management program. Start with a few metrics – either that you consider vital, or of the “low hanging fruit” variety – so you can get the Quality Management program up and running with a few conspicuous successes. Then you can add more metrics within more Categories as your Quality Management program matures.

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Here are the eight “Quality Categories”. As you know, these are detailed in the NACHC Monograph entitled The Quality Management Plan: A Practical, Patient-Centered Template. This is the document you were asked to read prior to attending this webinar series, and it’s available online at NACHC’s web site. In it, you’ll find both specific definitions and key underlying health care concepts for each of our Quality Categories. The eight Categories are: - ACCESS and CYCLE TIME; - COMPREHENSIVE, COORDINATED, and INTEGRATED CARE; - CLINICAL QUALITY and SAFETY; - PREVENTION and HEALTH PROMOTION; - PATIENT and COMMUNITY RELATIONSHIPS; - HEALTH INFORMATION TECHNOLOGY (HIT); - PATIENT SATISFACTION and LOYALTY; and - BUSINESS PROCESS QUALITY.

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As you no doubt recall, the process for creating specific metrics within each of these Categories has already been addressed, in the discussion of “internal and external metrics” from our second webinar. This is the process you’ll use to develop your health center’s own metrics within the eight Categories, by specific program or initiative.

Again, start simple… Ideally you might begin with one or two metrics within each Category (or even a metric or two within just a few selected Categories). As your program grows, you’ll add more metrics. The key is to start by learning the system and how to use it – that is, both creating and then measuring specific metrics – and then, with a growing comfort level for using hard data to make improvements, move on from there to expand the program.

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So let’s review the sequential steps in creating a metric within a program Category. After identifying the metric you want to address, establish an organizational goal for that metric. Often goals are stated as “100%” for things that are critical for the health center to be doing. When setting goals, the health center should build in some “stretch”, since continual improvement is a dynamic activity. Then develop the “quality action point”, or the level – measured against the stated goal – at which a metric would be considered unacceptable, and thus subject to immediate improvement activity. Health center leaders should review these action points at least annually and adjust them – hopefully ever upward – according to the health center’s current performance. From this point, the rest is mainly logistics. For each metric, the health center will need to identify the specific data source for measurement, determine how often the metric should be re-evaluated (depending on both its prioritized importance and the status of any related improvement activities), and prospectively assign the metric to a specific manager (by position) so it’s clear who “owns” the issue before any need is found for improvement. (This will go a long way toward avoiding any sense of a manager’s being personally “singled out” after the fact.) Created and Presented by: Ambulatory Innovations, Inc. 60

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The Quality Management Plan Monograph includes specific sample metrics within each of the eight broad PCMH-based Categories for four important programs / initiatives, as samples of how Quality Management can be a unifying construct across multiple health center components. These packages of related metrics for individual programs have been titled Metric Paks. While clearly there are many more programs and initiatives that could be integrated into this overall Quality Management structure, these examples have specific importance to health centers. - The Primary Care Metric Pak addresses the fundamental program of health centers. - The HIV and Behavioral Health Metric Paks address specific clinical initiatives that health centers may currently be attempting to integrate into their operations. - Finally, the Meaningful Use Metric Pak addresses this relatively new initiative that applies to all health centers.

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Let’s take a little closer look at these Metric Paks, which essentially provide a “plug-and-play” roadmap to the measurement activities that form the basis for ongoing improvement within the framework of an effective Quality Management Plan. NACHC’s Quality Management Plan Monograph arrays our sample Metric Paks in two complementary ways. Here is a sample of a Metric Pak with its Categories and related sample metrics arrayed by specific program or initiative (in this case, ”Primary Care”).

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And here are program metrics arrayed by specific Quality Category (in this case, “Access and Cycle Time”). Of course, both of these arrays are only examples from the comprehensive four-program metrics structure shown in the NACHC Monograph. The Monograph shows all sample metrics, from all Categories within the four sample programs.

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Here’s our final exercise… While it can be done by yourself, it’s probably most effective if accomplished with your quality team.

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OK… now that we’ve taken you through the fundamentals of quality and a health center’s Quality Management Plan, and have proposed a practical and patient-centered template for manipulating the metrics you’ll need in order to measure and continuously improve important health center programs, as a final step let’s look at how a health center can actually make this whole thing work. We’ll review some ways a health center can move the whole quality idea dramatically forward over time.

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Here are eight proven ideas for doing just that. We’ll take a brief look at each individually. Since the “meat” of most tips is on the slides themselves, we’ll follow our own Tip #1 and keep the accompanying narrative simple and brief...

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As we’ve mentioned previously, the idea here is simply not to bite off more than you can easily chew. By starting simple, the health center staff will learn how the program works, how to create metrics and fill in Metric Paks, and so forth. So… the answer to our question about eating an elephant that might otherwise seem “too big to eat” – it’s “one bite at a time”.

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Training is essential for anyone who will be an active part of ongoing improvement, and asneeded coaching will be vital. A reasonable idea is to give basic quality training to everyone, provide more technical quality training to Improvement Team members, and ensure that a strong quality coach is always available.

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Communication throughout the health center is critical in making this all work. So one of leadership’s main jobs is ensuring that everything about the Quality Management program is strongly and consistently communicated throughout the organization. This includes highlighting identified problems, as well as communicating quality-based solutions being tested. Important data and quality progress should be continually conveyed to everyone.

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A “bottom-line” issue is that Quality Management simply won’t work without constant leadership commitment. For instance, the CEO and appropriate managers need to be seen at educational offerings. And they must “walk the walk” every day, even when it’s tough to do. The CEO must make clear that world-class quality is the only acceptable course and must personally participate in on-the-ground quality activities. Since the concept of leadership is so crucial to the success of a health center’s Quality Management program, let’s explore it in a little more depth.

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As we’ve stated, the health center’s leadership structure must commit to making sure that all components of Quality Management are in place, and that everything aligns with the “quality vision”. Of course, leaders and managers must constantly underscore that vision.

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It’s no exaggeration to say that the key to a successful quality program is strong, unrelenting advocacy from all levels of leadership. Leaders and managers must understand – and believe in – quality and its impact on all facets of the health center. They must also understand all components and techniques of Quality Management. And they must be keenly aware of the impact of a quality program on the health of patients and their communities. As noted, leaders must both “talk and walk” quality and be program advocates every day, despite the time, energy, and resources this takes. They should stand committed to eliminating barriers that will inevitably present themselves. And finally, they should set high expectations: We maintain that dazzled patients, spectacular outcomes, and breathtaking efficiency are not too much to expect from a health center and its staff.

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Leaders and managers must constantly reinforce quality concepts and principles. Every decision must be made within that framework. Leaders should constantly guide and encourage other leaders and staff. It’s worth saying again: Leaders should of course “talk the talk”, but they must also genuinely “walk the walk”. Staff will be watching. What happens in the health center when things get tough? Do leaders still lead and manage in a way consistent with a Quality Management philosophy? It has been said of a ham-and-eggs breakfast that the hen is involved, but the pig is committed. While we don’t expect health center leaders to take things to quite those lengths, quality just won’t work without strong leadership commitment. And since moving to a true “quality culture” is definitely not an overnight transition, perseverance is an important characteristic of health center leaders. They must constantly look toward the quality vision and “hang in there” until it is solidly in place. Transforming the culture of a health center is not an easy leadership task. But again – it will be worth the trouble.

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Don’t just take our word for it. Experts – including those who have themselves been leaders of health care organizations – tell us the same thing. Here, for instance, is what one leader of a complex (and successful) health care organization has to say on the subject…

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And here are reinforcing quotes from two top management experts…

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Now let’s return to our list of ideas for making Quality Management work. Tip #5: Start making quality preparations immediately – even if your health center doesn’t yet have any specific accreditation or recognition plans. Make sure everyone is actively involved in Quality Management preparation. Create organizational alignment with the quality vision by making sure everyone is prospectively pointed in a common direction and using a common roadmap.

You can start now by taking your webinar learning to the health center and actively working with the right people to “tune up” your health center’s Quality Management Plan.

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All staff must be involved if Quality Management is to really work. Leadership must involve everyone and not be afraid to let all staff members participate actively in creating their own future. Leaders must make clear that positive change is necessary and will happen – then they must allow everyone to work without fear to make things better for the entire organization. It has been said that “People don’t mind change – they just mind being changed.” Universal participation in Quality Management will help achieve universal buy-in.

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Here’s another useful tip… The power of a sincere compliment can be startling. The compliment can come from anyone, to any other staff member. Les Wallace’s words say it all.

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And especially when there are quality victories, staff celebrations – even small ones – can be powerful motivators to continue the effort.

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Finally, all staff members must be proud of their quality accomplishments and use them as springboards for future successes. If a health center follows the preceding Tips, it will get there.

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We’ll let Dr. Krueger have the final word, from his decidedly patient-centered perspective…

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You can download all materials from today’s Webinar in PDF format, including the presentation with referenced resources, by clicking the appropriate link next to the one that opened this webinar. We hope you will view the entire Quality webinar series with a multi-disciplinary team of your health center colleagues, and that you will be able to find time to work with the included exercises. We would love to hear from you at any time with feedback and/or technical assistance needs you may have. Please email Katja Laepke at [email protected] with your questions or concerns. THANK YOU for joining us in this series of webinars on Quality Management. We sincerely hope you ultimately feel that your time was well spent, and that these webinars helped you become an integral part of fostering a genuine – and genuinely successful – Quality Management program through which your health center can continually improve for the sake of its staff, patients, and communities.

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Additional Resources:  NACHC Monograph: The Quality Management Plan: A Practical, PatientCentered Template  The Joint Commission (TJC)  PCMH Issues & Resources  Accreditation Association for Ambulatory Health Care (AAAHC)  Medical Home  Health Center Accreditation  Agency for Healthcare Research and Quality (AHRQ)  Quality and Patient Safety  Health Resources and Services Administration (HRSA)  The Health Center Program

Additional Resources:  American Academy of Family Physicians (AAFP)  PCMH Issues  American Academy of Pediatrics (AAP)  Policy Statement: Patient & Family-Centered Care and the Pediatrician’s Role

 American College of Physicians (ACP)  PCMH Issues  Practice Advisor  American Osteopathic Association (AOA)  PCMH Principles

Additional Resources:  The National Committee for Quality Assurance (NCQA)  Physician Practice Connections – Patient Centered Medical Home Recognition Program  Government Recognition Initiative Program  Qualis Health  Change Concepts for Practice Transformation  Safety Net Medical Home Initiative  MacColl Center for Health Care Innovation  Patient-Centered Primary Care Collaborative  Center for Medical Home Improvement

Additional Resources:  MGMA – PCMH Guidelines – A Tool to Compare National Programs  The Centers for Medicare and Medicaid Services (CMS)  Innovation Center  FQHC PCMH Demonstration Program  The Picker Institute  Principles of Patient-Centered Care  URAC  PCMH Recognition

 The National Association of Community Health Centers (NACHC)

Additional Resources:  Safety Net Medical Home Initiative  National Quality Recognition Initiatives: Comparison Chart (HRSA/BPHC)  Urban Institute – Comparison of 10 PCMH Recognition Tools  American Reinvestment and Recovery Act  HRSA Accreditation Initiative  National Patient Safety Goals

 ECRI Institute  NACHC PCMH Institute

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