Claire Hutkins Seda, Writer, Migrant Clinicians Network, Managing Editor, Streamline
Primary care is in crisis. With fewer health care professionals choosing primary care and with a growing demand for primary care services, millions of people around the United States find that they simply can’t go to a clinician when they’re sick. The problem is amplified for underserved patients like agricultural workers, who often haven’t established a relationship with a local clinic due to barriers like their mobility, language differences, cultural sensitivities, and poverty. Some clinics are taking time out for meetings to address this shortage. Through a new collaborative, clinics across the US meet to generate and implement plans to improve their workflow, in hopes of providing higher quality health care and more efficient appointments for their patients.
On a recent Monday, Seenamma Machireddy, MD took time away from her busy primary care schedule, seeing patients at Cherry Health in Grand Rapids, Michigan, to join her staff for a weekly hour-long meeting to check in on improvements to workflow they have implemented. In addition, every week, a team from Dr. Machireddy’s clinic, consisting of a nurse, supervisor, and site managers, logs into a two-hour virtual meeting with other clinics from around the country. The two weekly meetings are a regular feature of Cherry Health’s time commitment for the Improving Clinical Flow collaborative, which Cherry Health has been participating in for over a year.
“It’s been a learning experience -- and we’ve seen a lot of changes,” Dr. Machireddy noted. “Definitely, we were able to improve a lot of our quality measures.” When Cherry Health began the ECHO project, a primary goal was to decrease patient cycle times. The baseline cycle time was 69 minutes. “Now it’s been consistently staying around 50 to 55,” she said, providing new time for more patients. Such a goal improves accessibility of care for agricultural workers and other underserved patients who struggle to get appointments, by increasing the number of patients served, thereby increasing their likelihood of getting an appointment when they need it, and avoiding the emergency room when care is put off. “This definitely impacts patient satisfaction, of course, too,” Dr. Machireddy added, as patients with appointments spend less time in the waiting room. After just a year, the additional hours spent in the collaborative meetings has already paid off.
Two Approaches, One Collaborative
The new 12-month program fuses the Institute for Healthcare Improvement’s Breakthrough Series Collaborative with Project ECHO’s teleECHO clinics to give Federally Qualified Health Centers (FQHCs) like Cherry Health the tools and support they need to make significant changes in their workflow to improve quality of care for patients. The project is a test run, supported by the GE Foundation’s Developing Health US Program, to see how the two forms can complement each other.
The Institute for Healthcare Improvement (IHI) has been putting its Breakthrough Series Collaborative (BTS) model to work for two decades. “IHI takes these known changes that people have tried all over the country, and puts them into a ‘change package,’” explained Cory Sevin, RN, MSN, NP, Director of IHI. With the ‘package,’ the BTS model presents to its participants the system of changes that seem to help other organizations get better results in the target area. For this collaborative, the change package is mostly focused on creating and optimizing the care team, improving work flow, and removing waste.
IHI augments the ‘package’ with a suite of data tools that provides the participating clinic with updated information every month to map their progress over the course of the collaborative -- the tools that Dr. Machireddy and her team used to see how their cycle times dropped. The improvement team must upload data related to the clinic’s goal to the IHI system at minimum once a month. IHI cuts and pastes the data so changes over time are visible, and compares the data with sets from other collaborative teams. “Being able to put that data along with the change package in front of [the participants] every week for a long period of time -- that seems to help... the level of sophistication of the teams and how they’re able to talk about the data, understand the system changes over time,” Sevin noted. Dr. Machireddy found the data to be key. “Having baseline numbers on all the measures helped a lot, to gauge where we are, if we’re improving. If there’s not significant improvement, we look for a new alternative,” she said.
Elizabeth Clewett, PhD, Senior Program Manager with Project ECHO, believes IHI’s approach greatly enhances Project ECHO, a telementoring platform that has made significant strides in expanding primary care clinicians’ tools and resources to battle a wide range of health concerns in their patient population. The popular virtual meeting program is defined by four pillars, Clewett said: using technology to overcome barriers like making an expert panel available to clinicians in a remote region; bringing in best practices; supporting case-based learning; and initiating a feedback loop, wherein participants are surveyed and the program offerings are adjusted to best serve the needs of the participants in real time. Participants are brought together through webcams and high-speed internet, the only requirements to participate in the highly interactive virtual meetings. With the new collaboration with IHI, Project ECHO brings the technology and the experts, and IHI brings the data crunching and the expertise in transforming work environments for the best, most efficient outcomes.
“The hope is for expanding reach and deepening interaction,” Sevin explained. “This is a very early test to see what we can learn through the partnership and integration.”
Nuts & Bolts of the Collaborative Before the collaborative meetings began, each FQHC spent two months to develop their improvement teams and make sure their technology was up to the task of utilizing virtual meeting platforms and pulling and adding information to IHI databases. Next, they process-mapped their workflow to better understand their pre-collaborative state and provide baseline data. Then, faculty and improvement advisors stepped in to review the workflow and identify where improvements could happen. Finally, the collaborative officially kicked off, with a two-day, in-person learning session at ECHO headquarters in New Mexico.
Finally, the “Action Period” began, during which they tested out their first round of changes and measure their effects on work flow, Sevin said. A second virtual learning session was followed by a second round of action, to build on and spread successes from the first round, or back up and regroup, if the data weren’t showing significant progress. During this phase, the FQHC teams come together weekly for a two-hour ECHO call where brief didactics from ECHO staff are paired with case studies and roundtable discussions so that the community can learn from each other and build on each other’s successes. “The hierarchy of experts and teams and other clinicians is flattened in the belief that everyone has knowledge to provide,” pointed out Clewett, an important -- and effective -- aspect of the ECHO model.
On the ground, this is the time during which FQHCs plan out, implement, and then evaluate improvements with a PDSA Cycle -- “Plan, Do, Study, Act.”
“Our staff who are involved in the ECHO project really got a good hold of how to run PDSAs and how to measure success, and how to tweak things if things are not working well,” Dr. Machireddy said. Cherry Health’s first PDSA was to ensure that emergency room (ER) records were ready for practitioners for patients who were at the clinic for an ER follow-up appointment. While the goal may not seem lofty, the planning, the intention, and especially the data assure such a basic improvement is done efficiently. “We now have records on almost 100 percent of the ER follow-ups, which makes the flow much easier, and the visit is just in and out,” Dr. Machireddy noted.
Such efficiency improvements further assist agricultural workers by allowing for more time in the exam room with the patients. With higher rates of occupational injury, while combating various barriers like language, and with health issues rooted in the social determinants of health, agricultural worker patients can greatly benefit from even a few additional minutes with a clinician, who can dedicate time to a more detailed medical history, or can address a backlog of health concerns that an agricultural worker patient may have put off when not able to access care. Efficiency in the exam room may indeed benefit underserved patients the most.
High Level of Commitment from FQHCs
The collaborative requires a high degree of commitment from FQHC staff. A “day-to-day leader” is expected to assign up to 40 percent of his or her time toward the project. A “Clinical Champion” -- a clinician -- and a “Measurement and Data Leader -- ideally, an IT or administrative worker -- are also designated. An Improvement Team is tasked to “test changes and drive the work.” Finally, an Executive Sponsor meets with other executives monthly for their own parallel track, that makes the business case for making the changes on the frontline and assures executive level buy-in and collaboration.
The collaborative goes beyond practical fixes to the workflow. “We’ve worked with the frontline teams to [help them] understand the changes they’re making, and how [the project] relates to the financial vitality of their organization, because they care about it and they need to care about it,” noted Sevin. “When you optimize your care team, when you... optimize the roles of a medical assistant or a nurse, or you get more people in, when you understand what it means to get rid of waste so you can see more people… [you bring] that financial understanding of the changes of how the frontline operates. I think it’s a great innovation.”
Learn more about IHI at www.ihi.org. Learn About MCN’s ECHO Clinic offerings here, http://www.migrantclinician.org/project-echo Read about the GE Foundation at: www.GEFoundation.com.
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