PART 4 OF 4 | DECEMBER 2016
Staff Competencies to Support Population Health
Ronda (Roni) Christopher, DHSc, MEd
Overview
The first step in managing a patient
population is understanding risk and the
process of risk stratification as it applies
to health care. The healthcare risk
equation takes into account a broad range
of clinical and social vulnerabilities,
associated threats and probabilities, and
costs. Effectively managing complex
populations is challenging; it requires
attention to organizational structure and
systems. Staff competencies to support
population health are critical, and a
variety of tools are available to help
assess and build competency among staff
members. Specific opportunities and tools
include: 1) assessing current team
function with respect to 12 essential team
competencies, 2) a project management
framework that can be adapted for
patient care coordination, 3) an exercise
focused on identifying team members’
strengths, 4) a system-thinking
application, 5) a set of rules for using
data to help coordinate care, and 6) using
a confidence scale to assess parents’
capabilities.
Learning Objectives

Apply principles of risk stratification to
patient care and general operations.

Build population health and quality
improvement capacity for key roles.

Understand team dynamics.

Use system-level thinking to empower
staff and achieve better outcomes.

Apply critical thinking as to how data are
used.
In the health care industry, the term “risk” has different
connotations depending upon one’s point of view. From a global
perspective, risk is a financial calculation that is the basis of
provider-payer contracts. For instance, primary care measures
center on prevention, disease-specific outcomes and the plurality of
patient visits whereas acute care outcomes center on emergency
department visits, readmissions, discharges from intensive care
units to skilled nursing facilities and home care. Payment equations
may be upside, downside or a combination of both.
Local risk is determined by the general health of a patient
population (or a patient panel) and it is typically measured against
multiple goals (e.g., accountable care organization, Merit-based
Incentive Payment System [MIPS], contracts). Local risk is also
affected by social determinants. It relies both on treatment plans
and self-management plans, and requires care coordination.
Risk Stratification
A multifactorial and flexible process is necessary to identify
potential risks for a population of patients. It should include
retrievable data and patient reports, but it can be defined either by
a particular quality measure (e.g., How many patients have poorly
controlled asthma?) or a specific need (e.g., How many poorly
controlled asthma patients live in the 14132 zip code?). It requires
a thoughtful approach that relies heavily on well-trained staff to
mine and interpret data and leverage resources available outside of
the system. At its core, the process embodies the motto, “All for
one and one for all,” applying population health management
techniques to effectively balance measure-driven reporting with
population-based needs.
Staff Competencies to Support Population Health
By Ronda Christopher, DHSc, MEd
The healthcare risk equation can be expressed as
By
Ronda Christopher, DHSc, MEd
follows:
Risk = Vulnerabilities (Probability x Threats) x Cost
2. Access: The team works to ensure patient
access to care whenever it is needed. (Focus on
whether rules of engagement are clear.)
3. Communication: The team knows when and how
to communicate with patients about their
needs. (Focus on whether the team feels
informed.)
4. Huddles: The team meets weekly at a minimum
to discuss and plan clinical interventions to
benefit patients. (Focus on ability to identify
high-risk patients.)
5. Care: There is an emphasis on sympathy and
empathy among team members and with
patients. (Focus on whether the team is
consistent and caring.)
Opportunities and Tools
Managing the complexities of populations is not easy;
it calls for structure, well-designed systems and,
importantly, a knowledgeable staff with the
appropriate skill set. Assigning roles and
responsibilities within the team is essential for
population management. It is important to understand
how the team operates because population health
activities are not always fully reflected in job
descriptions (e.g., it may fall under “duties as
required”) and may cause stress in the absence of a
thoughtful approach.
Opportunity #1: Assess Your Current Team
Function
A survey tool developed by the Insight Institute
(www.InsightInstitute) has been adapted to meet the
needs of a patient-centered health care system. On a
scale of 0-100 (0-30 = “needs improvement,” 31-74 =
“average,” 75-100 = “area of strength”), the survey
captures each member’s perception of how well the
team performs with regard to 12 essential team
competencies.1
1. Roles and responsibilities: Every team member
knows her/his role and responsibility. (Focus on
whether flex roles are needed.)
6. Structure: The team consistently meets the
requirements set by the team leadership, the
organization and relevant regulatory agencies.
(Focus on whether meetings provide good
direction.)
7. Purpose: Every member understands the
purpose of the team’s work. (Focus on whether
we know what we are trying to do.)
8. Patient engagement: The team seeks ways to
improve relationships with its patients. (Focus
on whether patients are “in it with us”.)
9. Quality improvement: The team sets goals and
measures its ability to meet them. (Focus on
whether we readily apply techniques.)
10. Stress management: The team understands
what causes stress in the workplace and works
as a team to mitigate it. (Focus on whether we
know how to prioritize.)
11. Managing conflict: The team works to reduce
workplace conflict. (Focus on whether team
members are kind to one another.)
12. Patient satisfaction: The team reviews patient
satisfaction data for improvement opportunities.
(Focus on whether patients value the team.)
Essentials in Population Health | 2
Staff Competencies to Support Population Health
By Ronda Christopher, DHSc, MEd
Once
team
members
have
By Ronda
Christopher,
DHSc,
MEdcompleted the survey and
results have been compiled, leaders look for ratings
that fall into “needs improvement” and “average”
categories. A domain rated “needs improvement” by a
majority of members signals a serious deficit for the
entire team; if the poor rating comes from only 1 or 2
team members, it is likely an opportunity to build
competency. If staff members feel confused about
their roles and responsibilities, they will be unable to
meet goals. If perceptions of patient care or
engagement are inconsistent, issues with risk
management are more likely. Similarly, high stress
levels will result in suboptimal outcomes.
Opportunity #2: The RACI Tool
A project management tool that dissects key work
products outside of the typical job description, the
RACI Tool can be used to organize any focus area.
R = Person(s) Responsible for completing the task.
A = Person(s) Accountable for the outcomes.
C = Person(s) who must be Consulted (part of the
workflow).
I = Person(s) who must be Informed (aware of the
workflow).2
This tool can be adapted for patient care coordination
and used in setting goals with the patient (or
parent/guardian), helping the patient to list the
necessary takes to meet the goals, assisting the
patient in identifying key supports, and mapping a plan
for success.
Opportunity #4: Applying System-Level
Thinking
System-level thinking improves efficiency, helps
people work at their highest level of licensure, ensures
that population health strategies are employed, and
helps identify global and local risks. Data plays a key
role, but not the only role. A system thinking approach
takes into account the macrosystem (i.e., the C-suite
level that is concerned with the organization’s mission,
financial stability, staff and patient wellbeing, etc.),
the mesosystem (i.e., departments that are
responsible for fulfilling the mission, meeting targets,
etc.), the microsystem (i.e., frontline staff concerned
with patient care, communication, coordination, etc.)
and individual patients (i.e., source of the system’s
viability in terms of reputation and income).
Opportunity #5: Using Data to Coordinate
Health Care
Data can be helpful in answering questions or in telling
a story; the key to using data effectively is to carefully
define the issues and ask the right questions. To
become more knowledgeable about risk in order to
plan for efficient and effective care coordination,
certain data rules must be applied.
Clarify the request for data:

Follow the “golden rule” - always ask WHY?
(e.g., is the purpose of the request financial,
quality, data validation, or outreach? Do we
need a high level or detailed report?)

Follow the “silver rule” - always ask for
definitions. (e.g., Does diabetes include
gestational diabetes? Does pediatrics mean all
children under the age of 18? Does a “visit”
mean any visit?)

Follow the “bronze rule” – ask for time periods.
(e.g., Is the reporting period the same as the
“event” time period? Do we want to know if the
event occurred “ever” or within the last “x”
months?)
Opportunity #3: Know Your Team
The PDSA cycle is used for testing a change by
planning, doing, studying and acting on what is
learned. A tool that links the actions associated with
the four steps in this learning method with personality
types can help uncover and use team members’
strengths to their best advantage.3
Essentials in Population Health | 3
Staff Competencies to Support Population Health
By Ronda Christopher, DHSc, MEd
Choose a “data” strategy:
References
Tailor the strategy to the intended audience; macro-,
meso- and micro-levels require different types of data
and different degrees of detail.
1. Handley P. Lead with insight. Transform relationships,
increase teamwork, and improve communication. 2016.
Insight Institute Press, Kansas City, MO.
Opportunity #6: Assessing Parent Confidence
2. Kloppenborg TJ. 2009. Contemporary project
management. South-Western Cengage Learning, Mason,
OH.
Health care happens at a patient’s visit. Health
happens between visits. Education is just one of the
key elements in modifying behavior; understanding
parent/guardian capabilities is equally important –
especially in coordinating care. A Confidence Scale
(i.e., rating how confident the team is that the parent
will be able manage the child’s care between visits on
a scale of 1-10) is helpful in assessing a parent’s
capabilities with regard to how likely he/she will be
able to manage everything between a child’s visits. A
parent who is not confident at a 1-3 level signals
significant parental barriers to effective care
management at home. If a parent is confident but the
child is not, it is likely that the child has some
underlying anxiety.
3. Christopher R. What’s your PDSA personality? Licensed
under Creative Commons Attribution 3.0 Unported
License.
Ultimately, the parent and/or child will make their
own decisions. Confidence scales are an easy, valid
and effective way to gain insight into the decisions
made by the parent and child, and to assess whether a
care plan is likely to succeed.
Additional Reading and Resources
Advisory Board Company, Health Care Advisory Board (2013). Playbook for population health: Building the highperformance care management network. Available online to Advisory Board clients at:
https://www.advisory.com/research/health-care-advisory-board/studies/2013/playbook-for-population-health
Cambridge Health Alliance Model of Team-Based Care Implementation Guide and Toolkit. Available online at:
http://www.integration.samhsa.gov/workforce/team-members/Cambridge_health_alliance_team-based_care_toolkit.pdf
Solomon C. Moving the Needle: Getting things done in health care. The RACI tool for health care executives. The
New Group Consulting, Feb 2013.
Essentials in Population Health | 4