Using quality improvement strategies in the implementation of care management

An ongoing series of steps in successful care management is to apply the principles of quality improvement to the process of care management. This process begins with identifying the goals and activities of care management, identifying the patients to be in care management and how these patients will be engaged in care management, and then mapping out how care management will occur, with whom, and when. However, the ongoing process of tracking progress with goals and learning is in the territory of quality improvement.

Quality improvement (QI) in health care has been around for centuries, likely beginning with introducing hand washing to medical care in the 19th century. Now quality improvement includes developing and implementing strategies to improve both the process of patient care and patient safety. Implementation of QI in primary care has been shown to enhance the change process and create a culture of continuous change. Involving your care manager on practice QI teams, whether s/he is co-located or working remotely, can be an effective strategy for better integration and bi-directional communication.

Quality Improvement (QI) teams
What Is a QI Team?
• The purpose of a QI team is to intentionally examine how care can be delivered in a better manner – with more efficiency and/or more success. The overall goal is to improve the quality and efficiency of care delivered in the practice.
• They often include a representative from various areas of the practice including clinical and administrative areas.
• They often meet regularly (weekly/bi-weekly).
• QI teams are tasked with implementing change efforts.
• Care managers are often included as QI team members.

Why Use QI Teams for Change?
• QI teams help the practice understand the overall practice system: what is actually happening.
• They increase the diversity of perspectives.
• QI teams increase the number of staff empowered to identify and seek solutions to problems—“shared leadership.”
• These teams help create conditions for success, buy-in, and momentum. In our experience, a typical practice has people who tend to fall into one of these categories at these ratios: 20% want change, 50% on the fence, 30% against change. • QI teams use data to make sure changes are resulting in improvements.

Using flow maps and PDSA cycles to improve processes
The first step in improving an office system such as care management is to map your current process. Drawing a picture or a flow map of exactly how the process currently occurs can be a powerful tool. To create a flow map, simply list the current steps in order of completion. It is usually best to begin at the point where the patient engages the process (i.e., check-in). In order to draw an accurate flow map, it is also important to have all of the key staff involved. For example, you can’t map the check-in procedure if a front office staff is not part of the process. The following diagram is an example of one practice’s flow map for care management:

After the QI team has mapped out the steps, they will need to think about how well each step is working. Going beyond just whether the step is working, challenge each step of a process and consider if it is valuable, adequate, and flexible. Ask whether the step creates value for the patient, or is it a waste of time and energy?

In addition, it can be helpful to measure. If you encounter a process that is continually problematic, you may need to be more graphic in your evaluation by using a cause and effect diagram, also known as a fishbone diagram, to understand the root causes of problems. There are many resources on fishbone diagrams on the internet.

Next, consider the use of Plan Do Study Act (PDSA) cycles. PDSAs are small tests of change to see how they work. You may consider using worksheets to try and document these small cycles of change. A good PDSA Cycle Template can be found on the website: https://www.cms.gov/medicare/provider-enrollmentand-certification/qapi/downloads/pdsacycledebedits.pdf.

Complete the PDSA cycle by planning out the new step, trying it out (do), see how it works (study), and then try something else (act). For example, say you want to see how it works to have reception staff identify patients who might be eligible for care management. They get a list of criteria for eligible patients and steps for referral to care management. You have one reception staff member try to identify eligible patients for one half day, discuss how it worked, and try it again for a longer time period, or try something else if it didn’t work well.

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