North Cluster meeting minutes 8/18/09

CLUSTER OBJECTIVES
Quality improvement
Team building
8/18/09 North cluster MINUTES

KUDOs
Jason thanks to our MAs we appreciate you!
Ted, thank you to Core/Barb/pharmacy who all stayed late to help with patient

ANNOUNCEMENTS

BUSINESS
Time off- see separate form
Will check with Cindy on coverage for October 13-16 when we are short.

TEAM BUILDING What makes a good day? 1)predictability 2) good/easy communication 3) providers on time

1) Rooms: reminder to East on Tuesday AM from lakisha that we will be using 127-128
2) How’s your day feedback: going well, continue
3) Coverage for TED- ok’d by north cluster with request for box coverage help from other clusters on these afternoons

QUALITY IMPROVEMENT PROJECTS

1)Cluster board
a) CCM goal of 3/week- Kristi will give us progress each Thursday to help us meet goal

2) provider on-time cards (red/green) will try for several months

3)Green previsit forms: back to original going well.

4)**New Yellow forms: will get clarification from Chapman on this for providers

6) medication reconciliation: SEE NEW MED RECONCILIATION TO REFLECT PEND STATUS ON MEDS

7) continuity report: great job. Scheduling will be trying not to ‘hold’ appt and schedule on demand, we will see how that goes.

8) front desk skeleton crew from end of august thru September- LETS SEE HOW WE CAN HELP THEM, MAYBE CHECK IN EACH DAY?

9) reminders to do ‘todays work today’ and huddles on staffing and moral updates.

10) Emily will work with Core to see if we can improve immunizations process

North Cluster meeting minutes 8/4/09

8/4/09 NC Minutes

KUDO’s

Welcome to Emily Chao!

Thanks to Jason (MA) for helping prep north cluster charts!)

Thanks to Anna for helping out and being flexible

Thanks to LIZ for all that you do and all that you have given us!

BUSINESS

TEAM BUILDING

What makes a good day: 1)predictability 2) good/easy communication 3) timeliness of providers.

POTLUCK August 30th from 3-6PM

QUALITY IMPROVEMENT PROJECTS

1)Cluster board

• CCM goal of 3/week. WE DID IT, WE MET GOAL TWO WEEKS IN A ROW! KEEP UP THE GOOD WORK TEAM!

2) Improving Hedis by doing todays work today;

• Continue work on PAP/WCC/Immunizations and update colon cancer screening at each visit

3) HUDDLES for update on staffing

2)Previsit prep:

Working with new forms feedback next week

INSERVICE ON signing up MYGROUP HEALTH –thank you TED!

*ideally send patient to business office to do, as patient will get password that day, however,

If patient unable/unwilling here are the instructions:

1) open InContext

2) type in www.ghc.org

3) Put in patient ID

4) Click ‘register now’

5) Fill out self directed information

Patient will get password mailed to them

Encourage them to use it right away to reselect own password before it expires.

We will ask Becky to look into having administration acknowledge new sign ups with an ‘automatic reply’ feature.

Medication labeling reminder from LYNN

We are doing much better but several bottles not labeled with date they were opened. Just a friendly reminder that we have to throw out if they are not labeled.

Evolution of a Cluster Board

I would like to share an enlightening experience I had one recent morning on Workplace Rounds with our Primary Care leadership at Burien.

We spent about an hour in good discussion about the state of our clinic as represented graphically on our clinic level (tier 2) data board. These talks are always lively and, though I had initially dreaded them, they always lead to new insights and push our clinic group to improve our processes. I like these rounds.

Discussion continued in our East cluster while viewing our cluster (tier 1) board. It isn't always clear to clinical staff like me just what we're supposed to do with this kind of space. The stuff on the tier 2 boards is all data produced at the clinic level and is hard to adapt to daily flow.

But in clusters we don't really collect data. We see patients, we put them in rooms, talk to them, examine them, do procedures on them, give them medications, make plans, and send them back into the world to do and feel better. But we don't collect data. Or make charts. We're too busy doing work as it arrives, and it arrives fast, like a giant game of Human Tetris that runs non-stop all day.

So we'd been reluctant to wrap our arms around using data to run our day. One morning our team stood at the board, which was plastered with charts about things like performance on colon cancer screening last month. We asked of each chart, "how does this help me do my work today?" If a chart wasn't helpful, we marked it up to make it useful or took it down. It didn't take long before we had nothing on our board.

Better!

But still not helpful in doing today's work, so we made the blank board legitimately blank--and not just empty--by covering the space with white poster paper. We then added a question to the board: "How was your day?" The blank space now seemed a little more hopeful, a canvas instead of a wall. And people wrote about their days:

"I was behind all day and patients were mad at me."

"Great day. Great teamwork."

"Why was it so cold in here all day?"

This board became a place to describe the kinds of things that make days satisfying, great, or times of suffering and regret. It also became a place to stand and talk about those things, to celebrate the good and fix what was broken. And that process kind of helped us focus on doing better work "today," but the days sometimes still got out of control: we got behind, rushed, frustrated, and our patients got to feeling the same way.

So around we came that day on Workplace Rounds, and we talked about the evolution of that board from useless data heap to blank space to a free-speech zone, graffiti-style problem solving space. But still, it wasn't a real time board helping us problem-solve as problems appeared. And a good discussion started with this:

"Well, how do you know how you're doing when you're, say, halfway through the morning?"

"I just know. I know whether I'm okay or in terrible trouble. I feel it. Trouble is sometimes about being late, or a difficult visit I just had, or too much information coming too fast: pages, calls, questions, distractions. Does that make sense?"

"Sure. And if you're in trouble, what do you do then?"

"I usually say, to no one in particular, 'Wow, I'm really in trouble,' and then I put my head down and go back to work. What else can you do?"

"Mmm. Yes. What else can you do?"

"I...I don't know. I don't really know how the board can help with that."

And it sort of ended like that. No real idea of an answer, but my brain wouldn't let go of the question. It felt like the awkward stage of learning something in which you think you might be near a breakthrough, or you might just as easily be deluding yourself and will never figure out what the heck you're supposed to do.

Later that day our team talked and shared ideas about what a real time board might look like, one that helps you when the wheels fly off and you don't know what to do but curse and keep driving on screeching rims. We settled on a simple experiment with two pieces of paper: one red, one green.

Here it is. We've posted four laminated cards made from contstruction paper I took from my kids. Each care team (dyad) has one, marked by a letter, posted where they're visible to everyone, often. If things are going well, you show the green side. If things start falling apart, you flip it to red. There's no clear definition of when you go to red. You call that on your own: could be about time, could be about workload, anything.

When you need help, you go red.

Amazingly, this simple agreement to use a visible symbol to represent if things are okay or not goes a long way to making things okay more often. On the occasions when things aren't going smoothly, I flip to red, people see, and we can quickly talk about ways to get things back on track. We look for a catch up spot in the schedule, start a workup before I see the patient, call in flow staff backup, or shift a patient to another provider with an open appointment to prevent patients waiting too long. We improvise. Sometimes there's no great answer and the solution is just to let patients know things are behind, and this seems to be appreciated.

Overall, the experiment seems successful. It helps bring a healthy perspective to what's happening right now: Are we we doing what we've planned to do, and if not, how can we get back on track?

I still don't think I totally get how I might use the cluster board to help me with my day as I move from room to office to room, doing work, Tetris-style, and trying to keep myself in the flow, giving patients the care and the time they deserve. If I had a tool to do that--respectful of workflow, time, and patient needs--I'd use it.

And if I find it, I'll tell you.

North Cluster meeting minutes 7/28/09

CLUSTER OBJECTIVES
• Quality improvement
• Team building
KUDOs

Thanks to Alisha and Anna for helping with a complicated patient on Monday

Thanks to Jason for being only 1 of 3 providers here Monday afternoon!

Thanks to team for excellent job on med reconciliation, it shows when we cover other clusters boxes how well we do!

Thanks to Jason for reworking our previsit forms!

TEAM BUILDING

What makes a good day:
1)predictability
2) good/easy communication
3) timeliness of providers.

POTLUCK August 30th from 3-6PM

North Cluster Gallup
Great scores, you all are great coworkers! Please send in info on what things we are missing to allow you to do your job well (our lowest score) We want to make sure we address that!

QUALITY IMPROVEMENT PROJECTS

1)Cluster board
1) CCM goal of 3/week. WE DID IT, WE MET GOAL! KEEP UP THE GOOD WORK TEAM!

2) Improving Hedis by doing todays work today; WE DIALED IN OUR PREVISIT FORMS TO HELP CAPITALIZE ON THIS THEME!

3) HUDDLES on going.

2)Previsit prep: Goal is clear expectations all around:

For support staff:
Use outreach time to document last time the following 7 items have been done for the age range delineated on our North cluster prep sheet:
1) PAP,
2) FOBT,
3) Flex sig/colonoscopy
4) Mammogram
5) PHQ-9
6) diabetic foot exams and do if greater than 6 months (have all diabetics remove shoes)
7) immunizations MD’s to decide what is due and act on it appropriately

Also ask about MY GROUP HEALTH status and give info if not activated- Ted will do inservice at our next meeting to review how we can help patients do that, we can also send to business office (circle yellow sheet designation if patient willing to get done)

For providers:
We will be responsible for:
1) what needs update and be responsible for ordering/addressing with patients.
2) Addressing Chronic Care management plans with patients and ensuring we are using at least 3 a week

This is an evolving process so keep feedback coming so we can make it work for us so you have a great day!

East Cluster Meeting Minutes, July 22, 2009

Lots of great problem solving at today's meeting.

EXTERNAL RX: include phone/fax no. where to place folder?
- Red folder to be placed on provider’s desk on right hand side to be matched up with hard copy of prescription so they can go back to the pharmacy together.

3 YR. WCC: eyes/ear.
- Concluded that for 3yo wcc-no eyes/ears-a lot of work and often fruitless

Red Alerts; solutions?
- Create and use PA openings to handle overflow during the day

Routine immunizations for pregnant patients:
- No routine (live) immunizations, but ifluenza vaccine is indicated. Also see Penatal Care Guidelines on InContext.

Evaluate processes:
- Fish, red/green alerts, pre-visit prep
- For Future Agenda: check to see if above system is working or not (one month)

Limit rate of new actions:
- Limit rate of new actions-such as above
- So no one feels intimidated or stupid

Rap Sheets: should be put in pharmacy slot in AM ASAP?
-Rap sheet to be placed into BO slot for Faxing-was done by Anna-system not working; Becky will discuss w/ Mark to continue process-BO to do faxing

Lab requests that pt’s name, # be on FOBT card:
- will put pt’s name/initials, and CSN on stool cards when sending out or placed stickers on when pt is being seen

Refrigerator temp. readings no longer being done:
- Continue to keep refrigerator temp. eye solution needs be in refrigerator

Pregnant patients again:
- week’s of gestation needs to be noted on nursing note
- generic list of preps/guides-Cheryl has copies if one needs a copy

North Cluster meeting minutes 7/21/09

1) if everyone could write their days out on the calandar that would be great.

2) August 30th will be our potluck (Jason can make that day afterall!) I will send a formal invite soon.

3) Provider, please try to do 3 chronic care plans a week.

4) Previsit prep:

Green sheet on board to show this:

Support staff: review our HEDIS deficits like we have been doing during outreach times and write on green form

MD's: review missing HEDIS and reconcile if 'not due' and address if due (like we have been doing)

Support staff: do diabetic foot exams on all diabetics every 6 months, have them all take shoes and socks off for MD exam as well

Support staff:

Ask about MY GROUP HEALTH STATUS and see if we can get more patients signed up.

We will check and see how this is working next week.

Thanks to all of you for your hard work!

Cross-covering protocol

My sister asked for this cross-coverage protocol, which was developed by Sarah Philp last Fall and posted to the blog in December. We've got several new providers since then, so it's worth sharing again.

Enjoy!