PRACTICE TRANSFORMATION:
IMPROVING QUALITY AND SAFETY
USING A TEAM-BASED CARE
APPROACH
W. Martin Smith Interdisciplinary Patient Quality and Safety
Awards Program
University of Florida
Gainesville, Florida
Christopher Scuderi D.O FAAFP
University of Florida College of Medicine Jacksonville
Disclosures
■ I have no relevant disclosures…
■ Thank you to:
– Our presenters
– You for supporting this conference
– Dr. Ashchi
BASICS
■ The University of Florida W. Martin Smith Interdisciplinary
Patient Safety Awards Program is cosponsored by the UF
College of Medicine Continuing Medical Education and the UF
Self-Insurance Program.
■ This program provides start-up support for faculty and staff to
design and implement projects focused on reducing the
likelihood of adverse events or claims and/or patient safety
and clinical process improvements.
STUDY BASICS
■ 6 UF Health CHFM Clinics in Jacksonville who differ in size and patient
populations
■ Three 2 hour trainings with Ed Shahady MD spread over 1 year for each
clinic
– Certified as AHRQ TeamSTEPPS Trainer
■ Staff and providers evaluated clinics culture in standardized survey at 0,6
and 12 months
■ Data reviewed for each clinic
– Survey data
– A1C, LDL
■ Stakeholders Meeting
Details of Study
■
The majority of the care that primary care physicians provide revolves around
the prevention and care of chronic disease. Safety and quality of this care is not
possible without an effective office team, strong team communication and
efficient office systems. Most of the errors for chronic disease and preventive
care are related to errors of omission.
■
The objective of this project addressed this quality and safety gap by training 6
primary care practices (physicians and their office staff) on the tenets of teambased care using the Agency Health Care Research and Quality (AHRQ) Primary
Care Version of TeamSTEPPS framework. Practices ranged from an office with
one physician to a medium sized practice with 6 clinicians.
■
Each practice participated in a series of trainings by a TeamSTEPPS certified
master trainer during a one year period. Each practice’s staff completed the
Medical Office Survey on Patient Safety Culture (AHRQ) at baseline, midway and
at completion of training to determine perceived changes in team based care
behavior and quality of care and was used as a teaching tool during the training
sessions.
■
We sought to demonstrate improved patient outcomes through improved office
culture by tracking Hemoglobin A1c and LDL levels of our diabetic patients
before and after the training was implemented. Additionally, we asked each
medical director, practice manager, and lead medical assistant at the end of
the study to describe changes in office culture and systems.
Details of Study
■ There were 90 people who participated in the medical office
survey across 6 practices (26 clinicians, 61 staff, 3
unspecified).
■ For all practices combined, there was not a significant
improvement in the Patient Safety Culture scores over time;
however, several of the practices alone had improved scores.
■ A Chi square analysis of survey data between clinicians and
non-clinicians showed significant differences in key areas of
communication, working relationships and office procedures
where clinicians had a more positive perception on
communication items while staff had a more positive
perception on quality/safety office practices.
■ All PCMHs saw a decrease in the mean Hemoglobin A1c
results for their diabetes patients from before and after
training implementation with a mean decrease of 0.16 (p
value = <.0001) using the Wilcoxon sign rank test. Similar
results were seen with the LDL cholesterol scores for these
patients with a mean decrease of 4.01 (p value = .0001).
Conclusions
■ Success in implementing team-based care was dependent on
how each practice embraced the training.
■ Two of the practices had leadership turnover that affected
morale and operations
– This was evident in the survey results and even patient
outcomes.
■ Since we did not have a comparison group, improved patient
outcomes may be due to other factors besides the teambased training.
Study Data
Study Data
Study Data
Study Data
Study Data
Study Data
Table1. A1C and LDL values by clinic
Period
Group
N
Clinic 1
79
79
79
211
211
211
44
44
44
210
210
210
480
480
480
26
26
26
1050
1050
1050
Before
After
Before-After
Clinic 2
Before
After
Before-After
Clinic 3
Before
After
Before-After
Clinic 4
Before
After
Before-After
Clinic 5
Before
After
Before-After
Clinic 6
Before
After
Before-After
OVERALL Before
After
Before-After
*Wilcoxon sign rank test
Mean Std P-value*
A1C Dev
7.91
7.51
0.40
7.63
7.54
0.09
7.13
6.82
0.31
7.75
7.55
0.21
7.25
7.11
0.13
7.68
7.96
-0.28
7.48
7.32
0.16
1.92
1.43
1.57 0.015
1.91
1.75
1.52 0.762
1.44
0.83
1.08 0.199
1.80
1.61
1.25 0.012
1.55
1.49
1.20 0.005
1.64
1.98
1.26 0.290
1.72
1.57
1.31 <.0001
N
63
63
63
133
133
133
40
40
40
134
134
134
451
451
451
13
13
13
834
834
834
Mean
LDL
Std Dev
99.94
40.26
87.29
29.34
12.65
33.78
95.25
33.43
93.10
31.52
2.15
28.20
88.50
33.01
87.43
26.93
1.08
19.12
101.74 43.44
97.41
39.27
4.33
30.23
88.00
34.05
84.46
33.44
3.54
31.28
91.38
30.82
88.46
33.65
2.92
15.39
92.34
36.35
88.34
33.87
4.01
30.21
P-value*
0.001
0.380
0.746
0.627
0.025
0.414
0.001
BEST PRACTICES
■ Daily rounds
– Medical Directors should start their day saying
hello to each team member and taking a pulse
of the clinic
■ Make team meetings more interactive
– Encourage meetings to be participatory from
all members of the practice
■ Set a few measurable overriding goals for the year
– Have the staff understand where they are
going
– Wildly Important Goals
BEST PRACTICES
■ Shadow partners
– Have each member of your office shadow someone
who does a different job
■ Be willing to call brief “short informative meetings” when
necessary to clarify operations.
■ Daily huddles
– Encourage a morning huddle between medical
assistants and providers.
BEST PRACTICES
■ Develop protocols to clarify roles
– Clarify what are the expectations of your staff
– Narcotics, late patients, dismissing patients
– Standing protocols
■ Institute a monthly lunch ritual
– Develop non-work related rituals
BEST PRACTICES
■ Give immediate positive group feedback for outstanding
performers.
– Let exceptional staff know they have done a great job
■ Debrief after major events
– Take time to discuss lessons learned
■ Employ a suggestion box
– Encourage input on how to improve
BEST PRACTICES
■ Consider quarterly meetings with sister offices
– Try to learn from best practices
■ Cultivate a culture of understanding
– Encourage communication that fosters team
■ Office leadership should be passionate teambuilders
– Enthusiasm and passion from leadership can
propel the office in a positive direction
Common Struggles
■ Staff turnover
■ The poison pill
■ The whirlwind
Study Best Practices
■ Consistent leadership from Medical Director was most
important factor we could identify
– An engaged medical director was associated with
better outcomes
– Where there was leadership turmoil the staff
environment struggled
– Servant Leadership
Keys to Establishing a
Primary Care Team Model
■
1. Determine if there is a desire among your current office to pursue these change
■
2. Identify a servant-leader to lead this change.
■
3. Seek input from the whole team to develop a mission statement.
■
4. Commit to regular team meetings at a minimum of once a month.
■
5. Develop MA-provider teams who are regularly paired and have a daily morning huddle.
■
6. Establish standing orders and protocols for chronic care and preventative care and ensure buy
in of this throughout the practice.
■
7. Allow for open discussion of processes and protocols
■
8. Optimize your current EHR for chronic disease registries and improved patient access.
■
9. Use these chronic disease and preventative care registries to establish a baseline and
measure the team’s improvements.
■
10. Educate, cross-train and provide opportunities for advancing your staff
■
11. Consider adding/sharing second level team care (such as pharmacists, case managers) as
the team becomes increasingly financially successful.
■
12. Identify Wildly Important Goals and lead measures to address areas that need to be
improved
The Gift of Team
In Summary
■ There are many challenges to practicing medicine
■ We have a noble calling and we must always rise above the
challenges
■ We need to advocate and innovate to do what is best for our
patients, staff and colleagues
■ Team-based care is a tool to help do that
QUESTIONS?
[email protected]