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Quality Improvement CollaborativePractice and system improvements are essential components of health care reform. Though there has been debate nationally regarding the effectiveness of the Collaborative model on improving healthcare, it is a model that the staff at the Vermont Program for Quality in Health Care (VPQ), along with national experts in the field of Quality Improvement believes holds the most promise for improving the healthcare system.
The VPQ Collaborative provides a structure to help teams identify what they need to work on and gives them the tools to improve. It is a bottom-up approach that encourages and celebrates teams sharing not only their successes but their “failures” so that all the Collaborative participants can learn from the experience.  Testimonials from previous collaboratives
This year, 26 outpatient care teams from around the state focused on practice and system improvements, ranging from implementing an Electronic Medical Record (EMR) or becoming a Medical Home; to reducing wait times, no shows and telephoning issues. Teams measure improvement using the Microsystems Assessment Tool [1] . As a group, the teams saw notable improvement in “integration of information with patients”, “performance results,” “process improvement,” and “organizational support”. Two practices saw the potential for significant financial savings as a result of the Collaborative focused on “Reducing the number of prescription requests which do not see same day action,” and “No show rates.” The problem for the team focusing on prescription requests was that new e-prescribing software required increased staff time to manage. Focusing on creating a new process around prescription refills lead to real reductions in the number of prescription refill calls coming in to the front desk, thus a reduction in staff time spent on prescription refill related work (see figure 1). The practice team that chose to focus on “no show” rates experienced a significant decrease in the number of patients who did not show up for scheduled appointments. For one doctor in the practice, the “no show” rate decreased from 26.7% to 10.3%, and for the other doctor the “no show” rate decreased from 10.5% to .66%. Using these figures, the practice projects, over the course of the next year, it will see an increase in net revenue averaging 35,000 dollars per provider. Figure 1: Example of Improvement in Process for Prescription Requests for a participating practice
 VPQ QI Collaborative Outline [click on a section to jump ahead] What is the VPQ Quality Improvement Collaborative? [back to top]
The VPQ Collaborative provides a structure to help teams identify what they need to work on and gives them the tools to improve. The curriculum used Clinical Microsystems [2] as a foundation, along with the Care Model (originally the Chronic Care Model) [3] and the Institute for Healthcare Improvement’s (IHI) Model for Improvement [4] . The Model for Improvement uses small, rapid cycles, referred to as PDSA cycles for Plan-Do-Study-Act, to bring about change.
This Collaborative brought together 26 outpatient care teams from around the state committed to making their work more patient-centered and enjoyable. It was an eight month effort, designed for clinical teams to work on actual issues that address practice and system improvements. Teams focused on a topic or topics of their own choosing including Electronic Medical Record (EMR) implementation, Medical Home implementation, Pharmacy-Patient Safety and a variety of process improvements including patient flow, wait times, no shows, telephoning issues, cycle time, asthma planned visits, and patient continuity. The aim of the Collaborative was to create change that would lead to measurable improvement for patients and improve workplace morale and efficiency.
The faculty for this Collaborative was drawn from VPQ, The Vermont Area Health Education Centers (AHEC), and the Vermont Department of Health (VDH), Vermont Information Technology Leaders (VITL) and VT Rural Health Alliance (VRHA), as well as guest faculty with expertise in either Quality Improvements skills or clinical and technical content. Plenary sessions were designed to be relevant for all teams regardless of their clinical setting or topic of focus. Several specific curricular tracks were supported: outpatient practices participating in the Department of Health’s Blueprint for Health; practices interested in enhancing the efficacy of EMRs; and safety net practices involved with VRHA.
The Timeline
The Kick-Off Meeting on October 24 was attended by representatives from all participating teams and communities. It set the parameters and expectations for the collaborative, assigned pre-work and assessments. Each of these activities helped jump start the training efforts and assist each team with readiness skills. Following the Kick-off, one-day Learning Sessions provided didactic lessons on Clinical Microsystems and the Model for Improvement at both introductory and advanced levels. Learning Sessions were located in Montpelier, Vermont and included plenary sessions, educational session’s specific to the four curricular tracks, team working time, and team sharing. After each Learning Sessions, teams worked on tasks designed to make changes using the PDSA cycles. Then, results and lessons learned during these Action Periods were discussed at the next Learning Session. The Collaborative concludes with an Outcomes Congress to celebrate the successes and the lessons learned from over the course of the Collaborative.
Learning Session One on November 21, 2008 Results of their assessments were provided to each team and served as the foundation for determination of aims and actions for the collaborative. Working sessions included creating aim statements, defining patient populations, metrics and measure selection, creating actions plans and the uses of the PDSA model. Significant time was allotted for teams to work and accomplish these initial tasks.
Figure 2: Collaborative Timeline
Learning Session Two on January 9, 2009 was designed to showcase the successes and experiences of one of the participating practice teams and provide didactic instruction on specific tools and skills. Concurrent skills sessions were offered, a session on identifying change ideas and significant team time for action planning and coaching assistance. The concurrent sessions included process maps and flow charting, Model for Improvement Simulation, Fishbone diagrams and selection of measures and data collection tips and tools. Team time was organized around specific topics to encourage collaboration and maximize coaching.
Learning Session Three took place on March 6, 2009, and highlighted the successes and experiences of two of the participating teams. Concurrent skills sessions built on the work of previous learning sessions and focused on reinforcing process improvement skills, collecting and sharing data, spreading successful change, and sustaining and maintaining gains.
Coaches were assigned to teams throughout the collaborative to provide individualized coaching and a single contact. They were grouped along general focus areas. Each coach made a special effort to contact their teams or communities during the Action Periods, and to be available to provide support as needed. The Action Periods were when the majority of the Process Improvement work took place, with teams doing the work of bringing positive change to their practice setting. Two conference calls were offered during the action periods. The first took place through Webinar technology provided by VITL on December 16, 2008. The topic was a follow-up to the November Learning Session on Turning Data into Information. The second, on February 5, 2009, also used Webinar technology through VITL and was a review of the Microsystems tool, process flow mapping, fishbone diagramming, and metrics selection and collection. Participants seemed to find the technology easy to maneuver and helpful.
Lt Governor Brian Dubie welcomed participants to the Outcomes Congress on May 8, 2009 when storyboards and team presentations offered the teams an opportunity to showcase their work. Representatives from state government were invited to share in the celebration. Data collected during a reassessment of the teams demonstrated significant process improvement at both the individual team level and the statewide level.
History of VPQs involvement with the Collaborative Model [back to top]
In the fall of 2001, five staff members from the Vermont Program for Quality in Health Care (VPQ) attended the Institute for Healthcare Improvement’s Breakthrough Series College and returned to Vermont to launch the Vermont Community Diabetes Collaborative. The Collaborative used the framework provided by the Chronic Care Model developed by Ed Wagner, MD, MPH, (Director of the MacColl Institute for Healthcare Innovation, Group Health Cooperative of Puget Sound), and his colleagues during the 1990’s. The Chronic Care Model identifies six key components of a successful healthcare system: the community, the health system, self-management support, delivery system design, decision support and clinical information systems. Success is defined as productive interactions between an informed, activated patient and a prepared, proactive healthcare team. To achieve quality improvement with these six components the Collaborative teams were coached in the Model for Improvement. The Model for Improvement uses small, rapid cycles, referred to as PDSA cycles for Plan-Do-Study-Act, to bring about change. Nine primary care practices participated in the original Collaborative. Participants in this Collaborative worked exclusively to improve the care they were providing for people with diabetes; however, many of these early adopters expressed an interest in applying what they were learning to the management of other chronic diseases. Two additional Collaboratives were held expanding the state’s ability to improve and track care for patients with chronic conditions.
By 2006, the staff at VPQ identified a need to change how we were reaching out to the provider practices in Vermont. In many cases, despite strong interest in incorporating and spreading the quality improvement methodology being taught during the Collaborative into their daily work, small practices were unable to close their practice for a day or two to attend the Learning Sessions. Recognition of this problem coincided with the initiation of the Governor’s Blueprint for Health, and with the creation of funding for implementing provider training in six Blueprint communities. The new model of implementation was named the VPQ Learning Community and consisted of three components: centralized, statewide, single-day Learning Forums; multiple, community-based mini-learning sessions (the Collaborative on Wheels); and a virtual Learning Community dimension.
The VPQ Learning Community also began to incorporate a new methodology for improvement of the six components of the Chronic Care Model. This new methodology, called Clinical Microsystems, views the practice team as a microsystem of patient care within the larger healthcare system. It is based on the idea that improving individual clinical microsystems will improve the entire healthcare system. The methodology uses the five P’s: purpose, patients, professionals, patterns, and process, to identify areas where quality improvement needs to occur. Improvement is again achieved through multiple PDSA cycles.
VPQ staff subcontractors and the Area Health Education Center (AHEC) work with community leaders to provide a variety of training opportunities to the practice teams and develop a statewide quality improvement infrastructure. Currently over 11 hospitals and 134 provider teams or practices from around the state have participated in the VPQ Learning Community (figure 3). These provider teams consist of primary care providers, specialists, nurses, front office and administrative staff, as well as community members focusing on mental and social health issues.
Figure 3: VPQHC Training with Providers, 2001 – Present
Does the Collaborative Model work? [back to top]
Though there has been debate nationally regarding the effectiveness of the Collaborative model on improving healthcare, it is a model that the staff at VPQ, along with national experts in the field of Quality Improvement believes holds the most promise for improving the healthcare system. It is a bottom up approach that encourages and celebrates teams sharing not only their successes but their “failures” so that all the Collaborative participants can learn from the experience.
Anecdotally, past teams have demonstrated improved process indicators such as the number of people with diabetes who are taking aspirin and the number of people with diabetes who are getting their HbA1C checked twice a year. This year the teams were assessed using tools from the Clinical Microsystems methodology. The first is the Core Process Survey; a survey tool designed to help members of the practice team rate the processes that are part of their daily work and to identify areas within the practice upon which they could improve. Each staff member was asked to evaluate the process and the completed surveys were sent to VPQ for collation and aggregation. The teams were given the survey results in both numeric and graphic displays and were encouraged to look for the areas that were a real problem, totally broken, or a source of patient complaint (figure 4).
Figure 4: Aggregate Survey Results identifying areas across all teams for focused Quality Improvement
The second tool, the Microsystems Assessment Tool, is a self-assessment of the functionality of the practice micro system. This evaluation tool is first used to establish a baseline for each practice and repeated again at the end of the Collaborative, therefore, allowing teams to measure improvement. Again, the teams were given the results in both a numeric and graphic format (figure 5). The process improvement tools allowed teams to focus on the core process measures where they identified problems or complaints, and as a result many saw noticeable improvement in their Clinical Microsystem Assessment scores.
Figure 5: Aggregate Assessment illustrating Improvement across all teams
Figures 6 and 7 illustrate how these tools are used by individual teams or practices. The Core Process Survey (figure 6) identified several patient-related areas that the team could focus on, specifically “assignment of patients to your practice,” and “orientation of patients to your practice.” The practice then conducted a detailed patient survey to identify specific problems that could be addressed. The patient survey revealed confusion among patients with regard to office hours, who their primary care provider was, and what they should bring to each office visit. The practice addressed “orienting patients to providers and practice” through the use of a brochure as the improvement process on which they would focus. As figure 7 illustrates, this practice showed marked improvement in education and training, patient focus, integration of information with patients, and community and market focus.
Figure 6: Core Process Survey Results for One Practice identifying areas for focused Quality Improvement
Figure 7: Observed Improvement for One Practice using the Microsystem Assessment Tool
Another practice team focused on the work of being a Medical Home, and anecdotal patient stories from this practice indicated that the systems improvement work being done was also improving patient outcomes. A 72 year old patient with Type 2 diabetes began exercising regularly, maintained a blood sugar in the normal range, lost weight, and told providers that “she hasn’t felt this good in years.” Another 62 year old patient with hypertension, weight gain, anxiety and depression has created time for regular exercise, is maintaining a healthy diet, and has been able to stop taking acid reflux medications and decreased their blood pressure medications by half.
What are the VPQ Learning Forums? [back to top]
In conjunction with the work taking place with the VPQ Quality Improvement Collaborative, VPQ offered two Learning Forums over the course of the fiscal year. These Learning Forums were an opportunity to reach out to professionals who were not currently involved with the Collaborative, including both inpatient and outpatient settings, and representatives from the fields of maintenance, dietary, social work, and chaplaincy. In 2008 and 2009, VPQ used the Learning Forums to bring nationally recognized speakers to the area to speak on topics of interest to the Healthcare Community.
The first Learning Forum titled Building Bridges to Effective Health Quality Systems took place on November 13, 2008 in collaboration with the NH Critical Access Hospitals. Darlene Bainbridge MS, RN, CPHQ presented information about the Quality Calendar [5] , a survey readiness tool she developed. This tool is adaptable to every specialty department including hospital-based clinical practices. She currently assists 108 Critical Access Hospitals in the West and Midwest in their quality improvement and survey preparedness efforts. The Quality Calendar is a tool for incorporating quality assurance and improvement work into daily processes. Several of the hospitals that participated brought representatives from not only Quality Improvement departments, but also from housekeeping, maintenance and pharmacy departments. For more information about this tool please contact VPQ.
The second Learning Forum occurred on June 5, 2009, Narrative Medicine: From Theory to Practice to Results. During this Learning Forum, Healthcare Professionals including physicians, nurse practitioners, chaplains, and nurses listened and participated in exercises led by Craig Irvine Ph.D., from the Narrative Medicine program at Columbia University in New York City [6]. Over sixty participants, many of whom had never attended a VPQ offering, expressed excitement with the opportunity to share their own stories and to learn the skills needed to be better able to hear the stories of the people they care for. Many participants expressed interest in a follow-up to this Learning Forum.
What’s Next? [back to top]
We know from the accumulative experience and evidence from seven years of working with the provider community and the collaborative model that transformation will be most efficient, effective, and have the greatest chance of success if several components are included in the assistance. The three critical types of support that practices need to successfully transform their care delivery include financial, facilitation, and peer-to-peer learning and support. Our conclusions/findings are identical to those of other organizations around the nation who are engaged in similar initiatives[7] . As we move forward with health reform in Vermont, these three components must be a significant part of the process and must be fully funded.
Financial assistance may include money to purchase an EMR, equipment, and importantly, time spent for training and implementation. For small practices in Vermont, it often is the piece that addresses the final barrier to their active engagement in quality improvement and transformative care. We have found that even small financial incentives make a difference in allowing teams to intentionally schedule time for weekly meetings for planned changes and continual improvement. Blueprint Pilot Community funding for physician incentives to participate in collaborative trainings and implementation activities as well as coordinating qualifying payments for meeting NCQA Medical Home criteria across all insurers have been instrumental in the gains made by the primary care providers in our state.
Facilitation is not needed by all practices to the same degree but our data show that the practices that make the greatest gains have been most actively engaged in the facilitated learning offered by the collaborative approach and methodology. Understanding data gathered with the Clinical Microsystems Assessment Tool was seminal in their ability to identify areas for focused change that resulted in the foundation of a high-performing and high functioning practice. Practices require external support as they attempt transformative changes including strengthening the leadership and relationship infrastructure of the practice.
Peer-to-Peer learning and support speeds the transformation process. The opportunity for physicians and their practice staff to share their experiences and learn from one another is identified by Vermont primary care physicians as the single most important factor contributing to success in the difficult process of change. They consistently have reported that practices learned the most from each other. According to the National Demonstration Project of Transformed, “The physicians say the shared information and learning was invaluable, but even more powerful was the simple act of connecting to others on the same journey.” The Vermont experience mirrors their findings.
Next steps for VPQ include planning and delivery design for the next rounds of practice transformation support to Vermont’s primary care practices. We hope to continue VPQ’s quality improvement collaborative work with the Vermont Rural Health Alliance and the Vermont Department of Health. The aim is to advance those practices currently designated as Integrated Medical Home Pilots and provide readiness training to VRHA practices interested in becoming Medical Homes. Additionally we expect to be part of the training and clinical transformation VITL is planning for FY 2010 and beyond. If significant and sustained progress is the State’s expectation, then funding for support to practices with demonstrated effectiveness for addressing the transformation needs is necessary. Currently those resources are not aligned with expansion expectations for health reform.
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