4.1. Practice Improvement Program
In 2012, SFHP rolled out the second year of its pay for performance program, the Practice Improvement Program (PIP). The overall goal of PIP is to reward system improvements and drive better outcomes in clinical care and patient experience by providing financial incentives and technical assistance. Each measure selected allows for improvement opportunities.
An advisory board governs PIP, with member representatives from our entire provider network. This board meets several times per year to develop and approve measurement sets and advise on issues of both feasibility and clinical relevance of each proposed measure. SFHP’s Governing Board and Executive Team determine funding streams for the PIP program on an annual basis. Incentive payments were provided to PIP participants on a semi-annual basis. Each medical group and clinic’s potential earnings in the program were based on capitation rates and enrolled membership. In 2012, payments were based on 18.5% of Medi-Cal capitation, 7.5% of Healthy Families capitation, and 5% of Healthy Kids capitation. The incentive pool was set to be sufficiently generous to truly drive system improvements in the delivery system.
The second year of PIP continued to focus on measures in four main domains: Clinical Quality, Data Quality, Patient Experience, and Systems Improvement. The table below lists some examples of measures within each domain.
Domain Example of a Measure within Domain Clinical Quality
Demonstrate relative improvement on a QI Project focused on one of the participant’s three lowest scoring HEDIS measures.
Data Quality Submit 90% of encounter data within 90 days of the service date.
Patient Experience Conduct a project for improving patient experience.
Systems Improvement
Select at least three members of the staff, including a senior leader to participate in SF Quality Culture Series, or a similar leadership-training program; adopt meaningful use standards for electronic health records
implementation.
Participants in the second year of the program included 20 community health centers, six medical groups, and three individual providers. A few highlights of the 2012 program year’s success include:
31 All eligible sites (n=28) submitted a QI project plan related to a clinical area of focus, chosen from clinical quality indicators where the most improvement is needed 89% of eligible sites (n=26) engaged in a patient experience improvement project, which targeted improving either patient-provider communication, clinic staff customer service, or reducing wait times for primary care appointments
89% of eligible sites (n=17) adopted or made plans to adopt at least five meaningful use measures to better use electronic health record technology to achieve health, quality and efficiency goals
4.2 Provider Incentive Pilot to Support Patients on Persistent Medications In September 2012, SFHP piloted a provider incentive program targeting the HEDIS measure, Annual Monitoring for Patients on Persistent Medications. The eligible population for this measure is all members over 18 years of age who have received at least 180 days of treatment with an ACE inhibitor or ARB, digoxin, or a diuretic. To be compliant in this measure, a member must receive at least one serum potassium and either a serum creatinine or a blood urea nitrogen therapeutic monitoring test each year.
Providers who participated in the pilot received an outreach list of their patients who were not compliant in the measure. In order to receive the incentive, providers scheduled the appropriate screening test for their patients and documented the date that the test results were received and reviewed.
The goal of this intervention was to increase screening rates for patients with persistent medications while raising provider awareness of the intervention. Participation in the pilot incentive program was very low. However, we believe that by targeting different providers and increasing our communication efforts, future iterations of the incentive would see higher participation rates.
4.3. SF Quality Culture Series
San Francisco clinics face major challenges in preparation for healthcare reform:
ensuring timely access to care despite a primary care shortage, developing patient-centered medical homes in order to improve quality and patient experience, and implementing Electronic Health Records (EHR).
Studies on high-performing organizations frequently name leadership commitment and alignment as the foundation for success. Redwood Community Health Coalition, a
consortium of clinics in four North Bay counties, created the Quality Culture Series and saw a dramatic acceleration of improvements in the areas of chronic care, access, EHR, and patient experience, after 100% of their clinic leadership teams went through the training together. They attribute their success to the fact that the entire leadership team attended all sessions, then spread the training to their clinic staff.
32 San Francisco’s Quality Culture Series was based on this model. The initial year-long program consisted of 8 full-day interactive sessions, focusing on leadership and
management skills, quality improvement, and project management. Each clinic was assigned a practice coach, and all clinics participated with their senior leadership teams.
The series has been credited with increasing the pace of improvement in safety net clinics related to access, chronic care, and patient experience. In addition, clinic leaders had the opportunity to network and share best practices.
The series has been so successful that San Francisco Health Plan continues to sponsor the SF Quality Culture Series on an ongoing basis. In 2012, three follow-up sessions were sponsored for clinic leadership teams. The January session was focused on leading and managing change, and sharing data. 90 attendees from 22 clinics attended. In May 2012, the session featured Kumar Rajarum, Ph.D., from the UCLA Anderson School of
Management, who taught clinic leaders on key strategies to improve operations
management. Clinic leaders learned how to improve and manage processes, and explored tools to measure and analyze wait times, productivity, as well as decrease variations. 120 attendees from 27 clinics attended the session. The September 2012 session focused mostly on team-based care, and included topics such as creating teamlets (consistent provider-medical assistant pairs), defining the role of a nurse, legal scope of provider-medical assistants, and standing orders. 100 attendees from 26 clinics attended the session.
The SF Quality Culture Series has proved to be a transformative experience for clinic leadership teams. The excellent attendance rate, active engagement and program ratings across clinic participants demonstrate the high value they place on their experience. People cannot drive quality improvements without being able to manage people, change, and conflict, among other leadership, teamwork, and management skills. Thus, the fusion of the learning session content (management training, leadership development, quality
improvement basics) with training (learning skills to teach adult learners) was particularly effective.
4.4. Safety Net Quarterly Quality Meetings
The Safety Net Care Teams Quarterly Quality Meeting is collaboratively hosted by the San Francisco Health Plan, The San Francisco Community Clinic Consortium, and San
Francisco Department of Public Health clinics, both those at San Francisco General Hospital, and off-campus clinics. This meeting brings together clinic staff of all levels including
medical assistants, clinic managers, providers, and medical directors from safety net clinics across the city. This is a unique forum where all clinics are welcomed to come together to learn as a group and network, as well as share best practices.
Examples of Topics from Quarterly Quality Meetings Implementing Huddles Standing Orders
Safety in the Ambulatory Setting Effective Communication
Giving and Receiving Feedback Panel Management Best Practice Sharing
33 4.5 Coleman Rapid DPI Program
In 2012, SFHP sponsored nine clinics in its provider network to participate in Coleman Associates' Rapid DPI (Dramatic Performance Improvement) program. In this intense program, 3 to 5 consultants work side-by-side with clinic staff for one week, redesigning clinic processes to improve teamwork, patient access, and visit efficiency. This week is followed by two months of coaching, monitoring and reporting of performance measures, and continuous quality improvement.
The Coleman Rapid DPI program led to measurable operational improvements. For example, one clinic cut its new patient first-visit waitlist down by 67% (from 300 patients to 100) in three months and decreased its no-show rate from 30% to 24% over the same period. Another clinic made so much progress that it reset its goal of achieving NCQA Level I Patient-Centered Medical Home certification to achieving the Level III certification.
The Coleman Rapid DPI program also led to improvements in teamwork and patient centeredness. One clinic noted that tensions between front and back office staff faded away as their roles became more integrated and they started using walkie-talkies to communicate. Another clinic greatly appreciated Coleman's suggestion of using small gestures in order to make patients feel cared for during their visit and improve the overall patient experience.
To ensure that the changes implemented during the Rapid DPI process are sustained, SFHP is sponsoring a data reporting and improvement incentive program, as well as quarterly webinars for clinics to share best practices and compare their progress.
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