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!

North Cluster Develops a Medication Reconciliation Protocol

Cheers to the team up North for creating standard work we can all use to promote patient safety and get the medication list right every time!

Medication Reconciliation Protocol for North Cluster:
(DRAFT)

MA/RN/LPN Responsibilities:

1. INQUIRE
- ask the patient if they have a list and/or the pill bottles with them and reconcile their data with medication on epic
-ask about inhaled medications/OTC/herbals and PRN meds as well.

2. UPDATE
If a patient states they are taking a medication that is not listed on active meds, look in the historical meds and mark as taking and notify MD/PA on Yellow form/or PN of discrepancy.

3. DELETE
Discontinue all duplicate medications and completed courses.

4. VERIFY
verify with patient that AVS has been updated with RX changes and list has been correctly reconciled



MD/PA responsibilities:

1) REVIEW
review the med list for accuracy reviewing indications with patient and checking for understanding

2) UPDATE
-if any changes to medications made at that visit, ensure this has been reflected on medication list
(if not picking up new RX, rewrite and use 'update and file' tab)
-try to put indications on all RX to help patient understanding
-consider maximizing refills


3) VERIFY
if you are giving AVS, confirm with patient that RX list has been updated and changes reflected and confirm their understanding of the various indications

CORE MEETING MINUTES Tuesday 7/7/09

7:30 Immunizations
Staff agreed that during the “back to school crunch” we will need extra help. Immunization letters were sent out to parents encouraging them to bring their children in early .

– even with this letter, we still get the bulk of kids between end of July and up until the first week of September

Last year immunization sites were put in the clusters (as well as the core) and all the LPN’s working that day would give the immunizations along with us, unless they were busy.

Core Staff feel that this wound be a good thing to have again this year.

The state has made many changes in the distribution of immunizations. For now, the flow staff will not order immunizations but can check the consent form and hand out the VIS.

We still need all cluster staff to know that patient stickers need to go on the back and from of the stickers. Every day it seems like we are getting new guidelines for immunizations which makes it pretty confusing. Bobbie has volunteered to help simplify the process.




8:00 CORE Work Flow
Drop In Records- the number of monthly drop in’s for june increased from 52 to 53. These are the highest since tracking the drop ins began.
The data shows that Wednesdays continue be the busiest with the most drop in’s.

Core work flow (continued)
Wound care Records- The number of Wound cares that were done last month dropped from 146 to 125. Some of the reasons for this were because we were able to heal and discharge a lot of our patients. And this is the quiet before the storm.

Wound care has patterns of high volume and low volume.. an example would be: May- high number of new patients – why? Because the nice weather is coming and more people are outdoors

June drops off because people have gotten used to the weather, not as many injuries and school is still in.

We should see a rise in July as summer is in full bloom, kids are out of school… etc

Wound Care Days of the week The high volume days have changed. Since may. Last month our busiest month was tied with Wednesdays and Fridays. This would not of been so bad, but because Wednesday is our busiest day for drop in’s , the work load felt impossible to co. Our lightest wound care day was Thursday.

The goal for June was to even out the wound care days so that Thursday picked up and Wednesday’s dropped off.

This goal was met. We evened out the wound care so that all days are about the same.

8:15 Nurse of the day cell phone- CORE staff have proposed that they get a cell phone that the Doctors or flow staff could use when trying to get a hold of the CORE staff. This would increase communication between the core and the clusters. The Cell phone number would be put on the daily schedule. The CORE RN would carry the cell phone and hand it off to another staff member when leaving the premise. We were not able to finish this discussion due to time constraints. Will be put on the agenda next meeting

Referral contact menu

Cheryl asked me recently to post my referral contact drop-down menu to the blog. So here it is. You can create your own dot phrase in Epic with these steps:

1. In Epic, open Tools --> SmartTool Editors --> My SmartPhrases
2. Click Accept
3. Click Add
4. Make up a SmartPhrase Name (like ReferralTelephone)
5. In the SmartPhrase Text box, type this {:16687}

And that's it. When you use the SmartPhrase, you'll see a drop-down menu of contact phone numbers patients can call to schedule appointments. These numbers are only for Central Campus, though. I don't know of one for other campuses.

East Cluster Notes, July 8, 2009

Agreements from the East Cluster this week.

Our cluster board is developing nicely. We feel great about having eliminated or edited the information that didn't mean anything to us because the language was inaccessible, the print was tiny, the data or goals weren't clear, or the information simply didn't have anything to do with our daily work.

We like the "How Was Your Day" sheet, modeled on the pediatric pain scale, and have made the "suggestion envelope" into sticky notes to post on the board. This takes the invisible (notes hidden in an envelope) and makes them visible for all to see and discuss. A hard day for one of us might lead to a comment about what was hard, a suggestion for improvement, and a rapid change that eliminates the cause of the bad day. That's the power of writing on the board.

We also have our daily Fishing Reports on the board, but are not yet addressing these in an organized way to improve our access.

We will continue to use this "How Was Your Day" approach to bring up what's good and what's not, to solve what we can right now, and to discuss in our weekly meetings things that need a little more time.

Until next week, this is East, signing off.

Owning the Medical Home, Burien Style

I shared Burien's work on a couple of projects this week at the South Mini-Forum, and thought I would write a bit about it as well.

Through this process of launching the Medical Home at Group Health, Burienites (BRNites?) have sought effective ways to implement the creative piloting work our sister clinics and Primary Care Leadership Team. Excellent processes create solid standard work. Because of this, we enjoy the work, and we have excelled.

I think one of the reasons we've been able to sustain our enthusiasm is that we've explored ways to own the work and make the individual campaigns our own. Simply "receiving" the campaigns as orders in notebooks risks creating a culture of apathy (BRNouts!), staff who ace the checklists but don't feel energized by the effort.

So, how do we take very good ideas and faithfully put them to work at Burien while maintaining our sense of uniqueness, our sense that Burien is unique? It isn't easy! Or fast. Or linear. But owning the work is powerful, and worth the effort.

An example.

We're in the midst of launching the Prepared Visit effort. Goals: capitalize on opportunities to close care gaps, improve outcomes, and unburden our patients and ourselves.

When I look at the work from the perspective of various stakeholders, it's a winner all around: it looks pulls us out of the "tyrrany of the urgent," and helps us plan thoughtful care for our patients. But it is more work for our flowstaff, who are already heavily burdened with the daily demands of rooming patients, eliciting their concerns, reconciling their medications, making endless calls, handling provider requests, and moving information though our system. This doesn't begin to describe the amazing load of work our nursing staff accomplishes, and it is done with such efficiency and grace that it is largely invisible to me.

The idea of loading another task, and no small task, onto our flowstaff seemed like a guaranteed loser if handled poorly. More work? With what time? It seemed sure to feel bad all around if the work was introduced to flowstaff by boss-types who don't do the job and can't relate--really--to what another task means.

So we floated the Prepared Visit idea to a few of our excellent flowstaff, medical assistants with experience, smarts, and credibility among their peers. We asked these opinion leaders for their help: try out the work of preparing for visits before we launched clinic-wide, and share their experience. My medical assistant, Cheryl Rogers, took on the project with enthusiasm. I showed her a checklist five minutes before the end of a workday, and by the time she left she had already prepped one patient for the following day. Her response to the concept was enthusiastic: it was work, but it was worth it. She could see the payoff: preparation would improve patient care and lessen the burden of low-yield outreach letters and calls, work that consumes hours of her precious time every week.

The result. Cheryl and I have done more unscheduled pap smears in the last week than we scheduled in the last six months. And well-child checks. And colon cancer screens. Tetanus shots. Mammograms. Blood tests. Unbelievable, and very satisfying. And our patients like it--surprise. I've started running the checklist on my own with patients who send email.

By the time we had our launch event last week, everybody already knew about the project. They had watched their respected peers dive into the work and talk about it. And though we don't officially launch the project until next week, all of our flowstaff are already doing pre-visit checklists for our patients.

If you ask me, that's a successful launch. We're doing standard work (that we didn't have to create de novo), and we own the work because we presented it in a respectful way, engaging opinion leaders and allowing them to drive the process.

We are very fortunate at Burien to have a engaged, capable, and creative staff who crave meaningful work that matters to patients. Harness that spirit--rather than squash it--and we'll continue to lead the way in creating a model of what Primary Care really should be.

Crossposted at ghmedicalhome.org

North Cluster Minutes July 7, 2009

Thank you all for a GREAT meeting, we are covering a LOT and very efficiently!

Please see final medication reconciliation document. If I do not hear back on modifications, we will formally adopt and share with Clinic. GREAT WORK ON THIS, it has really made a different in our work and our patient care!

Items to do:

1) Please place your gallup survey in our envelope and we will give it a try. I would also encourage you all to look at East clusters "how was your day" feedback and I will check in next meeting if you would like to do that as well.

2) We will try our North Cluster Huddles:

With Flow staff meeting before each session to clarify who is here/what assignments look like/problem shoot etc.

Flow staff will update as needed their provider with the pass off of the first patient.

We will touch base next week to see how that is working.

3) try to do today's work today

Convert exam to WCC if due, add a PAP if due etc.

Lakisha and Ted being a trial for the Pre visit prep and will let us know how that is going. We will incorporate all of cluster in this next week.

4) Providers don't forget the CCM plans

5) Potluck dates.

Don't forget to give me feedback on dates you would prefer. List 1st, second and 3rd choice. Also if there are dates you absolutely can not make please let me know and we will try and avoid those.

Dates are:

July 19

July 26

August 2

August 9

August 16(actually this one we may be out of town, so may need to remove this option, sorry!)

August 30

They are all Sundays, time around 3-6PM, kids/partners welcome!

Thanks for being such a great team!

Diane

East Cluster Meeting, July 1, 2009

East Cluster had another great meeting on Wednesday morning.

We began by rounding at our cluster board. We like very much the "How Was Your Day?" daily survey, which gives each cluster member the chance to rate their day, 0-5 (five is a great day). An envelope tacked to the board gives us a chance to explain in words why we chose that number. We're not sure yet how to respond to what we put in the envelope: should we talk daily to address those things or wait until our cluster meeting each week? We agreed that if somebody's day was a one (ugh!), we should not wait up to a week to improve that?

Any thoughts on that?

Another thing about the cluster boards. A lot of the stuff up there (charts and text) doesn't pass Cheryl's very wise "plain English" test, which says that anyone walking by the board should be able to figure out quickly and easily what the information up there is trying to say. There shouldn't be jargon, tiny print, or charts that require a PhD in statistics to interpret. So we marked up our board with suggestions for improving.

But we didn't agree on who owns the job of updating the board.

We moved from the board to the roundtable and heard from Shannon (Pharmacy) and Sherrie (RN) about their roles in Chronic Disease Management. Here's a summary:

Shannon can help our patients who take medications for chronic diseases get to their treatment goals if we ask her help. She has protocols to adjust doses for diabetes and high blood pressure medications, and will call or see patients in clinic to follow blood sugars, blood pressures, lab tests, help with motivation, personal barriers to self-care, and any questions our patients have about their medications. She doesn't have a big case load now, and would love to see more of our patients!

Remember that she also has a separate blood pressure program for patients without complicated disease whose blood pressure is uncontrolled.

Sherrie and Christine, our RNs also take on patients with chronic diseases, including diabetes, asthma, COPD, heart failure, and coronary artery disease. They have two kinds of services to offer:

1. A three month chronic disease management program that involves several face to face sessions and a lot of telephone and email follow up. This focuses on many aspects of helping patients live well with chronic diseases and is best suited to newly diagnosed patients or those having a hard time controlling their disease.
2. A "treat-to-target" program that focuses on specific goals identified by providers. An example would be adjusting insulin dosing until the patient has met a target blood sugar goal.

Whether using our pharmacist or nurses, we should first create a treatment plan for our patients that lays out for them what goals we have agreed to. These always go in the After Visit Summary (AVS, or patient instructions), and will serve as the "orders" that Shannon, Sherrie, and Christine will follow, so we should be clear what we're asking.

Phew.

We wrapped up by learning from Frank that extensive testing of the air in the East Cluster showed that it's pretty good. Nothing dangerous in it. There's more mold outside than in the building.

Great meeting!

West Cluster Meeting Notes 7/1/09

Present: Kelly Walsh, Sarah Philp, Shannon Jewell, Sherrie Elmer, Jason Mateo, Star Morales, Ashley Lindell, Doug Knopp

Outreach; brief discussion on who is working on what this week…each of the flow staff is getting about ½ day every 1-2 weeks.

Cluster Social Gathering? Okay for a Friday in August? Email Kelly with dates that will not work for us.

Welcome, Shannon! Shannon discussed how she puts in medication refills and lab orders and documents in chart if she contacts patient. She states there is not so much Chronic Care Outreach being referred to her by the West Cluster yet. (See handout under Clinical Pharmacist Expectations).

Welcome Sherrie! Chronic Disease management; Sherrie explained how patients referred to RN’s work. These are patients referred for narrowed diagnoses (see handout under Family Practice RN expectations) and are followed for up to three months. When finished, these patients are warm transferred back to providers.

Voting for Flow Staff lead: Esma, Star and Jason all interested. We still need to decide whether this will be a rotating position (about every 6 months) or permanent position. Becky was working on developing a job description but we do not have it yet. It is hard to vote on this when we do not have a clear picture of what the job entails. Some people did not want to vote until we have the job description. Star brought up it would be helpful for the cluster to have each person's resume to review to help in decision making process. Each person interested will email the cluster their resume with an introductory paragraph of why they are interested in the position and then we can vote at the next meeting if the job description is provided.

Hedis- Flow staff pretty much caught up on Cancer screenings. Will add diabetes; Shannon states by the time the patient name is on the list, Pharmacy has already sent them two letters; so a phone call may work better. HTN- Wellesley already has a letter which we can send to patients asking them to come to the RN class. Star will contact him to get this and email to West Cluster before the next meeting. There are also two separate blood pressure goals for patients; diabetic and plain hypertensive.

Ashley brought her pre-visit dot phrase for labs; she will add no gum, gargling or mints to it and send to each of us.

Flow staff left at 1:40.

CORE MEETING MINUTES Tuesday 6/16/09

Wound Care Conference’s: is a meeting that is designed to create a “team” spirit among the wound care teams at all GH clinics. The purpose is to share challenging wound care cases, and get feedback and ideas from each other.

These Meetings will happen Bi-Monthly. Sheila will attend on the meetings on the 2nd Wednesday of every month and Pat will attend the meeting on the 3rd Tuesday of the month. Pat and Sheila will be presenting a case in July.

Warm Transfer forms: Dr. Chapman and the other PCP’s have approved the form. Once the forms arrive at the clinic, each wound care team member will in-service the flow staff in their clusters.

CORE Work Flow
1. Drop In Records have been updated for the month of May. Drop In patients continue to climb and Wednesday’s still have the most drop in’s. Core team are still looking for ways to offload work on Wednesday
2. Wound care Records: This is a new tracking system that will be updated monthly. The data shows how many wound cares we see each month and what days of the week are the busiest. This new tracking system is critical in estimating our flow staff needs. So far this year the core has done “716” wound cares.
3. Wound care Data: not a new tracking system, but equally important to show core staff the progress we are making. This is a Coop wide tracking system. It entails
a. the length of time it takes to heal a wound.
b. How many active wounds we have
c. How many patients are getting healed with in the target area
d. How many ( year to date) current wound care patients we have and those that we have healed.

Burien is doing well in all categories. We have the 3rd highest amount of wound care patients throughout the coop. (Olympia and Northgate have the highest.)

CORE MEETING MINUTES Tuesday 6/2/09

Agenda

1. Appointing guidelines
What’s new, impact on core- Due to the high volume of patients that we see in the core it has become more and more difficult to balance out the Wound cares and allergy appointments. In an attempt to correct this problem Cindy has been working and working on a new template and has finally come up with one that will work well in the core. Cindy deserves a big star!!! Even though the template looks different we still will be booking patients the same. (Well Cindy will)

Tid Bits
Drop In records: Core was extremely busy this month with drop in’s. we had 52 for the month of May. Sheila and P also had vacations which added to “busy” schedule. Some Questions and Idea’s for drop in’s was discussed:

1. Make a Sign that states: We are not an urgent care facility, and, this clinic operates by appointment only.

Will need Support from Becky, PCP’s and administration.

2. Go back to the way it used to be; Having Team RN’s evaluate and treat drop in’s. With Core assisting when Team RN’s are busy.

3.Communicate with CNS that all patients do not need to be seen the same day, and it would help if they communicated this to patient (“call clinic and make an appointment with your Doctor so that you are seen in the next 2-3 days.")

Warm Transfer
Form is now complete and has gone to Becky, Dr. Chapman and Jill who have all have given the “Go ahead”

1. Another thought for warm transfers was to get the core a cell phone

2. That way if someone (PCP’s, Flow Staff..Etc) needed something done for a patient they could call or text us. This would save time for everyone and increase communication.

3. The CP number would go on the daily schedule. Just like the “DOD” we could have “NOD” which would tell everyone who has the phone. Sheila would carry it unless she was out of the clinic.

North Cluster Makes its Own Gallup-style Poll

NORTH CLUSTERS GALLUP!

I would like to see the North Cluster continue to be the BEST cluster to work IN, and the BEST cluster to work WITH!

This self evaluation can serve as a feedback mechanism to raise our awareness on:

1) how do we as individuals feel about working with our team
(how are the team and its members working for you?)

2) how are we functioning as a team members (what are you doing for the
team and its members)

The questions are pulled from the Gallup survey we do once a year. The format of ranking each question 1 through 5 will be the same as well:
5= strongly agree/extremely satisfied
1= strongly disagree/extremely dissatisfied.
_____________________________________________________

In order to get your feedback on how you would like to see this, please answer the questions below with your preferences. You can leave this form in my inbox and I will compile the results and present at our next meeting.
______________________________________________________

1) FROM THE LIST BELOW PLEASE SELECT THE TOP FOUR QUESTIONS YOU WOULD LIKE TO BE ASKED, RANK THEM 1-4 (1=MOST IMPORTANT TO BE INCLUDED):

-There is someone at work who encourages my development.
-There is someone at work who seems to care about me as a person -In
the last seven days, I have received recognition or praise for doing good work.
-At work, I have the opportunity to do what I do best every day.
-I have the materials and equipment I need to do my work right.
-I know what is expected of me at work.
-I have had opportunities at work to learn and grow.
-How satisfied are you with the North Cluster as a work place.

2) HOW OFTEN WOULD YOU LIKE TO BE ASKED THESE QUESTIONS? (Circle ONE):

-once a day
-once a week
-once a month
-once every 3 months

3) PLEASE CIRCLE YOUR PREFERED FORMAT FOR ANSWERING THESE QUESTIONS (circle one)

-EMAIL (CONFIDENTIAL TO ALL EXCEPT RECIPIENT)
-FILL OUT ON CLUSTER BOARD (PARIALLY CONFIDENTIAL)
-WRITE ON PAPER AND PUT IN ENVELOPE (CONFIDENTIAL)

Thank you and feel free to write any free form comments as well! dd

North Cluster Notes June 23, 2009

CLUSTER OBJECTIVES
Quality improvement
Team building

KUDOS
-Thanks from Lakisha to Ted for staying on time, has helped her!
-Thanks to all for covering Diane during my absence
- thanks to all for being flexible with all these changes that we are working on toward reaching medical home!

TEAM BUILDING

Lead MA role, Becky wanting contact person- Staff to talk amongst themselves and get back to team next week with:
1) who
2) if rotating position
Becky to let them know rough job description and pay adjustment.

What makes a good day:
1)predictability – Liz with MA schedule doing well
2) good/easy communication sign out to Star before leaving, can leave message on her voice mail or email her
3) timeliness of providers. Doing better!

QUALITY IMPROVEMENT PROJECTS

1) Outreach
Put on hold PAP/colon cancer outreach till details flushed out and MA’s have more time, focus/priority on figuring out access and chronic care

2) Medication reconciliation: adopt July 7th any
-sugestion to check snap shot for duplicates and erase
-try use of .revami as a dot phrase in nursing not where discrepancies can be noted (especially OTC/meds not listed)
-ask about inhalers/vitamins/eyedrops/otc meds as well

3) Cluster board: goal to simplify- agreed to 4 reports for now:
-‘huddle’ time(required by admin)
-chronic care use-(required by admin) providers agree to work on emailing cc of chart where used to save staff from double work Goal of 3/week by each provider
-cluster satisfaction(see attached form to help create)
-avs

West Cluster Meeting June 24, 2009

Present: Becky Dolan, Doug Knopp, Ashley Lindell, Sarah Philp, Kelly Walsh, Jason Mateo, Esma Delalic, Mark Christianson, Star Morales

Chronic Care dot phrases: How are they going? Doug found one which was very tedious and time consuming.

How is everyone doing? Comments from Jason, Doug, Star and Esma

Discussion about patients showing up late and throwing off the schedule. The current standard is for the person making the appointment is to ask all pts to show up 10 minutes early. Pts have been showing up 10-30 minutes late for their physicals. Ultimately the PCR’s should check with flow staff or the provider to see if they can be put into the schedule if the pts are 15 minutes late, and pts are told they may have to reschedule.

New HEDIS letter is ready!!!

Medical Home:

Lead MA/LPN- discuss in cluster and choose before next meeting. There is an extra $1.25 an hour more; Becky is developing a job description.

Do we want Shannon Jewell to be at more than 1 cluster meeting every other week?

Do we want Team RNs attending meeting every other week?

Cluster board- where to place? Should we place in view of patients; somewhere for staff only; should we make it portable so we can bring it to the meetings and change?

HEDIS- Becky brought a new graph for Hedis measures we have already been working on to better view our progress; these are available to put on our board if we wish.

Pilot Program surrounding pre-visit work; Sarah and Diane are looking ahead on the schedule to see if pts are appointed appropriately (calling to convert OV to PV, etc.) this week. Also working on chronic care smartphrases more regularly. Jason is using the fishing report to look 1 week ahead and calling patients. Becky will get him skills list for each provider.

Pap smear dot phrase for patients signed up for online services was presented by Kelly. She will revise and email the final to us for use.

Mark presented the Future FP Appointment Continuity of all Burien Patients Chart.

Meeting Minutes from 6/17/09

WAY TO GO NORTH CLUSTER

We got through a LOT in a very short time. Thanks for everyone being on time, that was super helpful!

See red highlights for discussion decisions/topics addressed and new items from this meeting

TO DO FOR NEXT WEEK:

JASON: -will review how to do colon cancer screening outreach.

MA/LPN: Please come up with a plan for PAP outreach (calls/letters/email) and please plan on picking someone to present that to the team.

EVERYONE: pick one item you would like on cluster board , EMAIL TO ME THIS NEXT WEEK AND I WILL MAKE A LIST and we can agree on 4-6 measures to start with)

Thanks for all your participation!

You guys are the BEST!

Outreach

Start doing more active outreach now with Caulda here to help with access

1. PAP outreach: Ma/LPN to look into ways they would like to start doing this and report back to team next meeting
2. Colon cancer outreach: Jason to present next meeting things to consider when doing outreach

^{Predictability}

^{MA/LPN schedule available ahead of time, they will review for accuracy to help Cindy out}

^{Liz will assign our cluster each day (Cindy will notify us if cluster staff being pulled out and for what reasons)}

QUALITY IMPROVEMENT PROJECTS

1) Medication reconciliation: any input from shadowing that would change protocolWe will visit this each week for June to tweak as needed and if ready vote to adopt as our standard protocol July 7^th.

2) tier I board,

Where do we want it? Decided to hang on Lynn’s portable wall (work order placed)

What do we want on it? Discuss next visit, we ran out of time

-staff satisfaction/by day or week?( Diane working on format)

-avs

-virtual medicine

-fishing report

-fluorid- access-% chronic care with Tx plan-hedis

West Cluster Meeting Notes 6/3/09

Present: Kelly Walsh, Sarah Philp, Ashley Lindell, Becky Dolan, Shannon Jewell, Esma Delalic, Jason Mateo, Star Morales

Thanks to nursing staff for working HEDIS measures on cancer screening; Kelly is seeing patients who are aware of their need for colon screening.

Provider schedules are in the process of being approved for Fall. Amy will start in October.

Discussion of HEDIS letters; providers are getting inquiry about the wording for the colonoscopies; a copy of the letter is distributed to the providers. The letters are copied from what the East cluster mails out. The West providers will discuss and maybe revamp the wording or take out colonoscopy all together as this requires a referral and can be done if there is a positive hemoccult.

Back to the Medical Home list; Proactive Care

What are we doing already? Looking ahead on Hedis list a day or so before

How do we decide what to do next? Be more proactive; can we notify appointed patients before visits (to come in fasting or that they are in need of a pap)? Each nursing staff can be responsible for 1 provider weekly and can email MyGHC active patients ahead of time… Providers will discuss and get back to nursing staff.

There is no more shortage of the shingles vaccine. If a shingles vaccine is ordered, direct the patient to go to the Business office and check on their coverage and if they still desire to get the vaccine, go to the Core to register for the injection room.

Meeting closed at 1:40PM

North Cluster meeting minutes 4/13/09

CLUSTER OBJECTIVES
• Quality improvement
• Team building

April 13, 2009 Great meeting: in attendance Lakisha, Liz, Alisha, Anna, Becky, Ted, Jason, Diane

• KUDO’s
We did a great job with PEEPS, thanks for all who could help with inspirations/time/creativity
-we are managing the largest panels per FTE, thanks for everyone for going above and beyond!


• BUSINESS

Time off
Caulda will be in 4/17 and 4/24, then start 0.8 time 4/27/09 M-F
4/17/09 Diane at CME, Levine to cover Jason and Diane’s box in am
4/27-28 Jason out for CME

Outreach
Plan for this week: Sounds like providers not really aware of the ‘game plan’ despite heroic efforts by MA/Rn to inform us (thank you)! We will shoot for an MA presentation next week on what the overall plan has been and what is working/not working, and of course how we can all improve our outreach.



HOW IS YOUR DAY


Epic schedule: Becky will help if any trouble spots, just let her know

Xray request from AndreaMarcek:
It is difficult to prescreen appointments at end of the day.
Becky will talk with Radiology and see if hours can get shifted from 830-530 and check in with Administration to see if they can ease up on any penalties Andrea is getting if she has overtime.

• QUALITY IMPROVEMENT PROJECTS


Medication lists: how do we want to reconcile
We did not have enough time to explore completely:
For next meeting:
Consider how we can all contribute to improving our medication lists reconciliation. Bring ideas/suggestions to meeting and we can share and maybe make a North cluster guideline.
HAVE A GREAT WEEK!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

CORE MEETING MINUTES 4/7/09

Tuesday, April 7th, 2009
7:30- 8:30 AM
Doctor’s Lounge

Agenda
7:30 Injection Room Meeting Minutes:
New Policy on Staff and PPD shots- Yearly PPD test are no longer the practice at GH. (Unless of course you work in respiratory therapy area’s. etc….) new Hires will still be required to get a series of 2 PPD tests.

Anyone that has a positive or suspicious result will be required to get a Chest X-ray and follow up with their PCP

NDC numbers will now need to be entered on all patients receiving medicare. GHC is starting small with immunizations and the 81 drugs listed on the Injection Room Matrix. Training will occur at each clinic by the CIS Consultants, (Kitty). Official implementation date has not been defined

Flu campaign is all most over. Extra Vaccine can be returned to the Pharmacy. The plan for administering the vaccine did not work well this year. A lot of the patients we sent over by providers to get the shot, as they should of.)

The problem was that the patients that got the injection went back and told their friends and then we started getting those patients. This happened so often that by the time the flu campaign started a lot of the injections had been given, so much so, that the nurse that came to clinic specifically to do injections was slow and often sat reading her book.

8:10 Nadia Duffy Attended core meeting to discuss power outage and medications
• Review and updated Procedure manual. Nadia also introduced the new type of bag to use for medications. Revised who to contact if there is an outage. Sheila will create an algorithm for this. Nadia will get 4 new keys made so that the “contact” staff will be able to enter the building

West Cluster Meeting April 1, 2009

West Cluster Meeting April 1, 2009

Present: Becky, Mark, Doug, Kelly, Sean, Esma, Timieko, Jason and Star

Discussion about vitals station; should we build a room around the current nursing station or get extra equipment? Since it may just be 1.5 – 2 yrs before we get a new building maybe we can just get by without construction. We will try with maybe just another scale and a thermometer and see how this goes. Becky will order scale and thermometer.

Tackle box- providers could consult and give nursing staff a list of what would be useful in a kit to take to rooms for joint injections rather than providers going to the West injection supply room for supplies. We can buy the tackle box(es 1-2) and submit the receipt for reimbursement.

Discussion about 5th provider seating; Becky checked with building contractors and no sinks can be removed from current provider offices without a lot of added expense. If someone who is not working with patients can just have a safe place to put their personal belongings; they can use:
1. Room 127 or this can be converted into Dr. Knopp’s office
2. Can put a computer into Christina, RN’s previous space
3. Can put another station into one of the current provider offices

Meeting closed at 1:40PM

Star Morales, CMA

Simplified Outreach Targets for Flow Nurses

Here's a draft of a simple, one pager to help flow nurses go after patients with outstanding need for quality improvement.

Children's Immunizations

Children 2 years of age need the following shots:
• Diphtheria, tetanus, pertussis (DTaP) (4 doses)
• Inactivated polio virus (IPV) (3 doses)
• Measles, mumps, rubella (MMR) (1 dose)
• H. influenzae type B (Hib) (3 doses)
• Hepatitis B (HepB) (3 doses)
• Chickenpox (varicella) (1 dose) or documentation that they had chickenpox.

Diabetes
DM: HbA1c Test*
Get a hemoglobin A1C at least once a year
DM: HbA1c >9.0%*
Get the hemoglobin A1C <9
DM: LDL Screen*
Get an LDL once a year.
DM: LDL <100*
Get the LDL cholesterol <100
DM: Nephropathy Monitoring
Get a microalbuminuria test once a year.

Heart Care
CAD: Persistence of Beta Blocker Treatment
IF patient has had a heart attack, THEN the patient should be on a beta blocker (atenolol, metoprolol, or carvedilol).
CAD: Cholesterol Management – LDL Screen*
Get an LDL once a year.
CAD: Cholesterol Management – LDL<100*
Get the LDL cholesterol <100
Controlling High Blood Pressure*
Get the most recent blood pressure in clinic <140/90

Screening
Breast Cancer
Get a mammogram every two years for women 40-69.
Cervical Cancer
Get a pap smear every two years for women 21-65.
Colorectal Cancer
Get fecal occult blood test every year for patients OR get a colonoscopy every ten years for people 50-80.

Cluster Meeting 3/30/09 Minutes

Cluster Meeting 3/30/09 Minutes:
In attendance: Lakisha, Liz, Alisha, Anna, Diane, Jason, Ted, Becky

GRATITUDES
Great meeting and great team!
We can do Kudos each week and show and tell/or an unknown factoid each week for Monday morning ice breakers, nice way to start our week!.


BUSINESS
-upcoming time off:
4/17/09 Dozois out for CME
4/27-28 JW out for CME
4/8-13 Peds out

- rooms : East cluster to get back to us on room 127 &128 use on Monday & Tues AM and Wednsday PM's

-computers working on this!

- Peds room configuration:
Water pitcher: if ok with Lynn, will put in MA’s office against window.
File cabinet on other side of room divide to left of Lynn’s desk
Coat rack requested for peds room with 4 hooks

- invite Nill to participate when he can at meeting to include peds perspective



HOW ARE MA/RN'S DOING

Providers doing better with messages, helping a lot, keep up the great work

HOW ARE MD/PA'S DOING
Things have been going great, flow seems to be working well!


HEDIS MEASURES
Fluoride update, we are doing better! Will get quarterly reports
AVS update – we are doing well, keep it up 100% for Ted whoo hoo!

-outreach time for staff : we are getting consistent outreach time and Ma/RN using it to prescreen upcoming visit for hedis

- providers doing good with telemedicine and phone visits

-+ FOBT follow up- had to table for next meeting, will be addressed next visit.



other agenda items

-potluck/party- not addressed but I would love to have folks over with family to my house when it gets sunny so we can hang and let the kids and partners play!

CORE MEETING MINUTES 3/17/09

CORE MEETING MINUTES 3/17/09

7:30 Patient/staff calls are still coming back to the core.

 Marc says that all clinics area dealing with this and that as soon as a solution comes up, he will up dates us. Marc suggested that the core starts keeping track of the blind transfers

 PTM from downtown was trying to get a hold of a Per diem staff person. The call was misunderstood and the PTM was transferred to 3 other clinics so that she could “talk to the injection room nurse about traveler shots”

 Core has noticed more mistakes being made when it comes to patient appointments. Pt has a appointment card which clearly states day and time- pt shows up at clinic tries to check in, appt time or date are wrong, they are then sent back to core so that the core staff can handle it.

 This practice will now be handled by the PCR’s and the flow staff for that PCP. Patients will not be sent back to the core

8:10 MAs still need to be trained in core. She will take a look and see what days are good for training.

West Cluster Meeting Notes 3/25/2009

West Cluster Meeting Notes 3/25/2009

Booking appointments too close together;

Will discuss with call center to question people (spouses or adult children who need to accompany pts) to make sure there is enough time in between appts if each person is booked in the same day; we had one booked 20 minutes apart in different areas of the clinic and our patient had dementia and needed the family member there…
Flow staff can ask pts to please try and coordinate appts…

Huddles- What do we do? It is different for each provider (some prefer and some don’t)
Saves time
Get room ready
Getting follow up records before visit if possible
Long range planning

Working with ONE team (flow staff and PCP) is better for patient.
Huddles go more smoothly to anticipate patient needs

Outside records tracking;
Whoever schedules the ER follow up visit should request outside records. Who does this?

OB vs. Non-OB provider. Deal breaker or not? Dr. Levine is interviewing female providers for a .7 or a .8 FTE position. Need someone friendly and patient oriented who is also personable and team oriented.

Jason Mateo, MA

JM/sm

Decisions From East Cluster 3/31/2009

We agreed on the following priorities for future work:

Develop procedures for looking ahead on the schedule and trying to meet patient needs before the visit

Develop our skills in doing regular email outreach to patients (including establishment of communication etiquette, checking to see if patients use email)

Further expand upon our outreach efforts related to quality of care. Items to work on include: 1) creating standard operating procedures as to how outreach should be done; 2) creating a list of high value frequently used smart phrases that are kept updated; 3) simplifying the list of quality outreach targets; 4) creating a simple list explaining the different medications involved in outreach; 4) ensuring that everyone has good preference lists to ease ordering

As a further note, issues that were brought up but not delved into related to lack of standard practice among docs in the use of the PHQ9 and what expectations are for physicals.

3/23/09 North Cluster Minutes

Discussion CLUSTER MEETING GOALS/OBJECTIVES

The cluster meetings are pivotal in the success of our Medical Home Model.

The goals set forth for the clusters are very specific and straight forward.

1) create the highest level of teamwork possible

2) create the best cluster/clinic in regards to:

HEDIS scores,
wound closure rates
application rates for pediatric dental varnish, usage rates for the AVS, chronic condition coding


-Discussion on item #1:

1) focus on off loading our nurses, a priority of the MD retreat. Nurses feel providers are doing better on the number of result notes being sent to the inboxes, and providers doing better at batching those notes. this is helpful and appreciated. Keep it up!

2) Using the dot system consistently helps smooth cross coverage of providers, thus helping the team function together.

3) Use the yellow patient discharge sheets helps the team flow patients better. Patients know where they need to go, nurses can help direct and core/lab are better informed of providers intentions.
A suggestion was made that those sheets be kept inside the red folders to help remind patients to keep them out (and not fold up and put in purse/pocket)

4) consider a 1/2 day retreat for the North cluster once we have both Emily and Caulda on board, maybe sometime in the fall, to help team build and shape our focus

Discussion on item #2
1) try to get weekly numbers on fluoride usage
2) try to get weekly numbers on AVS usage
2) pick several Hedis measures to start focusing on. Items suggested at today's meeting included:

-PAP
-Colon cancer screening
-6 month pediatric vaccinations
-Mammograms
-HTN

3) Chronic condition coding
we will need to look into how to approach improving in this arena

4) wound closure rates
see how I can get numbers on our patients with open wounds, how do we track/follow?


SCHEDULE CHANGES

Emily Chao(pediatrician starting in August) and Caulda (starting April 27th) will be working M-Th , both will have Fridays off Ted (starting May 4th) will be Tuesday through Friday with Mondays off.

The only change this will require is in support staff coverage for Ted on Tuesday afternoons if Lakisha can not change her schedule. We have enough MA's in the afternoon so either way that should not be a problem.

OFFICE CHANGES

Office change has been completed with phones transferred over. Diane is at Shiji's desk, Nill is working up front with Lynn, and Anna at the MA's office.

We need to confirm that this will work with Emily when she arrives, realizing this is a temporary solution till we are in our new building.

there will be an additional computer/desk set up next to Emily's desk if we have student overflow.

We are working with East cluster on our high volume days which are Tuesday mornings (5 providers in) and Monday AM and Wednesday PM with 4 providers.

TIME OFF UPDATES

in order to better coordinate our cluster staffing and ensure there is adequate coverage and no 'surprises' we will try and get updates at least two weeks in advance for small 1-2 day abscences and more lead for longer 'vacations'.
encourage everyone put days out on big calandar behind Anna's desk

Wednesday 3/25 Diane is out all day for AP2 program (associates program mandatory for new GHP hires) no other abscences noted for April.
Jason out first two weeks in May


OTHER AGENDA ITEMS
no other agenda items brought up at meeting.

3/17 Provider meeting minutes

3/17 Provider meeting minutes
Present: Ashley, David, Diane, Doug, Jason, Kelly, Ted, Wellesley
Absent: Caulda, Marty, Sarah

1. reviewed events/updates
2. cluster meeting debrief:
a. all felt that it was worthwhile to continue weekly meetings. Worth the access hit for maintaining a culture of teamwork and improvement. Also felt that the amount of time was appropriate, though most clusters were really only having 30min meetings with late start times and needing to room those 8:40/1:40 patients.
b. North and West have felt behind because so much time has been devoted to personnel changes and moves. Plus, over paneling in North has prevented any outreach that involves adding appointments.
c. East cluster has been doing well, especially in the recent month with a renewed focus on team and making life better for nursing staff.
d. Many felt that the focus of these meetings should be teamwork and efficiency, and to specifically downplay or eliminate HEDIS from the mix since those will happen if the first part happens. HEDIS can seem like an insurmountable barrier to some, but can serve as a rallying point for nurses.
e. Many also agreed that it is still valuable to have a solution to a problem that does not stick and then to revisit it again. As long as we are promoting a sense of problem solving in the process, and not just complaining. All improvements should be seen as trials, and if a solution is not permanent, it is not necessarily a failure.
f. Need to keep things goal oriented (Wellesley suggested a goal of good nurses’ lives, for example) and measureable (could be something as simple as asking nurses how they are doing)
g. All agreed that sharing info would be great.
i. Forum may not be the best time to do it because some providers can never make it. Also, forum is so valuable, the sharing would be limited to very brief FYI’s only, and not include the discussion that we all felt was necessary.
ii. Blog is nice as a reference, but is not looked at much (sorry W)
iii. Regular meetings, especially of cluster leaders, would be best.

Decision: add noon meeting every 4th Tuesday for cluster leaders and anyone else who wants to attend. Diane will coordinate and remind providers of initial meeting next week.

Jason

PS. I created a dot phrase for all of our email addresses for pasting into an Epic staff message (a pool would not work). To compose a message to all BRN providers, do the following (this looks unnecessarily complicated, but I wanted to teach folks who don’t know a few very useful keyboard shortcuts that are faster than right mouse clicks):

1. Create a new message
2. in the “notes” section (body of the text), type “.1smproviders” (1 for our department as always, sm for staff message)
3. hit “control” and “A” to highlight the text
4. then hit “control” and “X” to cut the text
5. click mouse cursor in the “To” section
6. hit “control” and “V” to paste the text
(note that unfortunately, it will often look like that field is still blank, but the addresses are there. If you want to confirm, arrow to the left.)

Minutes for North cluster meeting 3/16/09

1) change in cluster leadership. Thank you to Jason for leading the past 6 months!
Diane will take this on next 3 - 6months

Alisha/Liz will help co-lead

3) change in schedule

Caulda will start 4/27/09, working Monday through Thursday with Friday off.

Ted will change his schedule starting 5/4/09 with:

Monday off, working Tuesday through Friday with Tuesday being a full day and thursday morning off.

Lakisha will check with her schedule to see if that works for her. She will work with Ted/Cindy/Becky on this and let us know.

Our cluster meeting may change to Tuesday morning starting the week of May 4th.

4) desk changes

By April 27th, Caulda will take Diane's desk

Diane will move into Shiji's old desk

Peds will move to Anna's desk

Anna will move to MA office

We will have to pick a 'move day'

Cindy has already put in request for phone changes. We do need to keep same numbers per protocol, so we will wait for ISD to do this

Anna's computer has been already set up in MA office

5) Abscence coverage

we will check in each week with the cluster regarding planned abscences for CME/vacation

Liz has volunteered to bring down master calander for us. we will try and make sure we cover our own cluster when possible.

6) HEDIS working group

Ted presented idea of a working group cluster meeting periodically. Some discussion was had but we did not have enough time to give it adequate attention.

table for when we are at our full capacity in may?

7) Liz brought up concern regarding MA's being sent out of cluster.

I discussed with Cindy. She is only doing that when there are cross training issues (ie out of cluster MA"s wanting to work in North to do more peds, or needing our MA's to cross train at core etc. She assures us that she is not doing it randomly and when no other clinic demands, she tries to keep the clusters whole.

8) Peds schedule

discussed with Cindy, once we formalize our cluster meeting she will convey to peds provider the need to be in on that day.

9) rooms

will ask East Cluster about their extra rooms at end of hall.

March 11, 2009 West Cluster Meeting Notes

March 11, 2009 West Cluster Meeting Notes

Present: Kelly, Timieko, Esma, Star, Jason M., Diana, Doug, Ashley, Mark.

Discussion about moving the results board to the current area where the Saturday board is to be more visible for patients to see our progress.

Flow staff would like to switch places with the two boards due to the Saturday board having employees phone and cell numbers listed. No one opposes this.

Providers discussed recent phone calls / TE’s received by Call Management with not enough info for the provider to deal with the call. ? from one person mainly. Is Call Management stretched too thin? Too many people out or sick calls lately?

All PE’s need 6 labels, please.

All female PE’s over 65 should still be completely undressed for pelvics even though they do not necessarily require paps.

Flow staff can pend immunizations, give paperwork for immunizations, pend paps, hemoccults, mammograms, etc. to save time for providers. Can also enter vitals data into paperwork brought in; make sure pts have Release of Info with label on it with outside forms.

Flow staff please review chart quickly, if pt has had depression in the recent past or is on antidepressants, please give PHQ9 before provider gets into room and enter into computer if possible.

Kelly brought up the “Good Day Flow” from the East cluster blog, we can all read this and discuss at our next meeting.

Meeting closed at 1:36PM

Star Morales, CMA

West Cluster Meeting Notes 3-3-09

Present: Becky, Doug, Sarah, Kelly, Ashley, Jason, Star, Esma, Sheila

With new clinic hours and meeting moved to earlier time; patients should start at 1:50PM after cluster meetings.

Discussion about Core referrals. Sheila joined us to discuss Core referrals. Her cell phone will be printed on the day sheet for providers to call her directly should they have a question or new wound care patient that needs her attention. Otherwise she would like the providers to walk over any invasive procedures such as: new wound care patients, anyone requiring IV fluids, or Foleys.

Meeting adjourned approximately 1:30pm.

Star Morales, CMA

Jason's procedure dot phrases

Jason sent out some of his favorite procedure and counseling dot phrases. He notes, "I use them all the time. Some are complete visit notes (the ones that usually will have a scheduled procedure), others are just procedure notes (the ones I usually just squeeze into the appointment). I've included my names for them as well, but feel free to adapt to your own technique and make into your own phrases if you want."

_____________________________________________
(jprocbx)

.id presents for biopsy of skin lesion.

Informed consent obtained. Area prepped and draped in sterile fashion. ***cc lidocaine + epi and bicarb administered intradermally. Using ***mm punch, bx done without difficulty and sent to pathology. *** sutures placed using 4-0 vicryl. Area dressed with abx ointment and bandaid. Pt tolerated procedure well.

Pt instructed to leave dressing on until tomorrow, then take off and leave open as desired. Keep clean with soap and water. Return in 1 week for suture removal. Watch for signs of infection (hot, red, pus draining, fever, etc).
______________________________________________
(jproccast) I also use this one for splinting too. Example "short arm thumb spica cast applied to RUE…."

*** applied to ***. Sensation and circulation is intact post application. Care instructions were given.
______________________________________________
(jproccirc)

.id presents for circumcision.

Informed consent obtained from parent. Pt placed on circumcision board.
Area prepped and draped in sterile fashion. 1cc lidocaine administered in ring block at base of phallus. Circumcision done in usual fashion with *** gomko. Minimal bleeding. No complications. Pt was dressed with vaseline gauze. Pt tolerated procedure well.

Parent instructed to leave vaseline gauze on at least 1 hour and then to replace with another vaseline gauze afterwards. Discussed warning s/sx of bleeding and infection. F/u prn.
______________________________________________
(jproccryo) - for this one, I just add a number and an s if there are multiple lesions. I am sure to include in my exam the description of the lesions (location and dx) so that I don't have to refer to it here too.

cryotherapy to lesion described above x 3 freeze thaw cycles
______________________________________________
(jprocendometrialbx)

.id who presents for endometrial biopsy for post menopausal bleeding.

Informed consent obtained. Pt placed in lithotomy position. She had normal external female genitalia. Speculum exam reveals a healthy appearing vaginal vault and cervix without discharge. Pap was done. Cervix was cleaned with betadine and sounded to 6cm easily. Endometrial bx done in usual fashion with 2 passes. Bimanual exam is negative with normal sized and freely mobile uterus and unremarkable ovaries. Pt tolerated procedure well.

Pt to be contacted with results. If neg, anticipate just following sx. If rebleeds, may need u/s.
______________________________________________
(jprocganglioncyst) - for ganglion cyst aspirations

Informed consent verbally obtained. Area prepped with iodine and alcohol. Intradermal lidocaine with epi administered over ganglion. With large bore needle, approx ***cc viscous material aspirated from cyst reducing the size completely, then 5mg kenalog injected into cyst space. Area cleaned and bandaid placed. Pt tolerated procedure well.
______________________________________________
(jprocid) - for I+D

.PROCEDURE:
Informed consent obtained. Area prepped and draped in sterile fashion. Incision made with 11 blade approximately *** cm long. Purulent material expressed easily, swabbed and sent for culture. Pocket explored and irrigated. ***cm of ribbon gauze placed to allow drainage. Good hemostasis achieved. Area cleaned and antibiotic ointment placed over incision site then dressed. The patient tolerated the procedure well.

ASSESSMENT:
*** abscess s/p I+D

PLAN:
Sent for culture. Keep area clean. Return in *** days for removal of drain/wound care. Signs and symptoms of infection discussed.
______________________________________________
(jprocingrownnail)

.id presents for partial toenail removal for infected ingrown nails. {RIGHT/LEFT:16} {MEDIAL / LATERAL:10360} aspect of great toe nail ingrown with mild swelling and erythema of surrounding skin.

PROCEDURE:
Informed consent obtained. Area prepped with iodine and draped in sterile fashion. 10cc 1% lidocaine with 0.5% bupivocaine plus bicarb administered as digital block. Nail was elevated, and 1/4 of nail edge was cut and removed without difficulty. Drysol with pressure achieved good hemostasis. Area cleaned and antibiotic ointment placed over incision site then dressed. The patient tolerated the procedure well.

ASSESSMENT:
Partial nail removal

PLAN:
Reinforced cutting nails square, massage of skin off nail edges and warm soaks in future for prevention of further episodes. Signs and symptoms of infection discussed. Keep dressing on until tomorrow, then cover only as needed. Hot water soaks tid after that. Follow up prn.

______________________________________________
(jprocinjection) - based on how our injection rooms seem to be stocked, I'd guess that most of you use depomedrol instead. But this kind of dot phrase saves me a lot of time and addresses all the concerns that India had about out documentation.

Informed consent obtained. Area prepped with iodine and alcohol. Using sterile technique, injection into *** done using 27g needle administering ***mg kenalog, ***cc 2% lidocaine, ***cc bupivocaine. Pt tolerated well and felt some improvement in sx.
______________________________________________
(jprociud)

.id presents for IUD placement. See prior note for more details. She took ibuprofen 800mg prior to coming in.

Informed consent obtained. Pt placed in lithotomy position. Bimanual exam was negative, speculum inserted revealing normal vaginal mucosa and cervix without discharge. Area was prepped with iodine. Tenaculum was placed and the uterus was sounded. *** IUD placed in usual fashion without difficulty and strings were trimmed. Tenaculum was removed. Pt tolerated procedure well and there were no complications.

Pt instructed and taught to feel for the IUD string monthly to confirm retention of the IUD after menses. In addition, she is counseled to call or return for fever, worsening pain, unusually heavy vaginal bleeding, suspected expulsion, or foul vaginal discharge. Stressed STD prevention.

______________________________________________
(jproclaceration)

PROCEDURE:
Informed consent obtained. Area prepped with iodine and draped in sterile fashion. ***cc 1% lidocaine + epi administered locally. Laceration closed with *** interrupted sutures using 4-0 vicryl with good skin approximation. Minimal bleeding. Area cleaned and antibiotic ointment placed over incision site then dressed. The patient tolerated the procedure well.

PLAN:
discussed signs and symptoms of infection. Return to remove sutures in 5-7 days.

______________________________________________
(jprocsebcyst) - note that I include measurements of the cyst since that matters for coding. Also note that for most of these, I actually now use punch bx rather than scalpel.

.id presents for cyst removal. Cyst measures *** cm located on ***.

PROCEDURE:
Informed consent obtained. Area prepped and draped in sterile fashion. Local anesthetic with intradermal lidocaine with epinephrine. Shallow elliptical incision made with 15 blade approximately *** cm long. Sac removed in entirety with hemostat. Wound irrigated with normal saline. *** interrupted sutures placed using 4-0 vicryl. Good hemostasis achieved. Area cleaned and antibiotic ointment placed over incision site then dressed. The patient tolerated the procedure well.

ASSESSMENT:
sebaceous cyst

PLAN:
Keep area clean. Return for suture removal in *** days. Signs and symptoms of infection discussed. Follow up prn.

______________________________________________
Lastly, these are my counseling dot phrases. I call them J (all my dot phrases start with J), then 50 (for 50), then 3, 4, 5 (for level 3-5). The *** should be filled with content relevant to your discussion or a reference to that elsewhere in your note. Could also be coordination of care, but I find that most of my time dependent ones are more counseling related, so this suits me well.

j503new
More than 50% of this 30min face to face visit was spent counseling ***

j504
More than 50% of this 25min face to face visit was spent counseling ***

j504new
More than 50% of this 45min face to face visit was spent counseling ***

j505
More than 50% of this 40min face to face visit was spent counseling ***

j505new
More than 50% of this 60min face to face visit was spent counseling ***

East Cluster Meeting Notes, 2/25/2009

East cluster met today and spent some time reviewing what we've done in this first six months of dedicated cluster work.

To focus our attention on some goals (and hopes), we talked about what makes for a good day at work. Here are some of those ideas:

• Manageable schedules (enough time to do our work)
• Doing something specific, tangible, for a patient that helps them to feel better
• Having a well-stocked cluster
• Having time for providers and nursing staff to plan and reflect
• Attention to detail
• Appropriate appointing
• Running on time
• Helping colleagues to keep things running smoothly
• Great teamwork
• Providing good emotional support for our patients as well as good technical care
• Hearing back from our patients that they're happy with their care
• Seeing our colleagues smile
• Creating a safe, trusting environment for patients
• Giving our patients the care we would like for our families
• Feeling relaxed, ready, and confident
• We wouldn't need to see the quality numbers, because we would know our work exceeds expectations

We also discussed some barriers to having a good day, every day.

• Appointing challenges: some preventive exams should really be problem-oriented, for example, as there is a lot to do in a preventive exam
• There are very different practice styles among our providers. The providers agreed six months ago to standardize some of our practices, but our actions haven't matched our words.
• Some processes are difficult to standardize and create consistent flow breakdowns in our busy days. Immunization reconciliation, ordering, and delivery is one of these areas. A protocol would help everyone feel more confident that we'll get the right immunizations to our patients.
• Medication reconciliation is a huge job for our nursing staff, and a great benefit to our patients and the providers who advise them. Again, there is not an accepted standard for reconciling medications, and we sometimes create work for our pharmacy in the way we do it. A protocol would simplify things.

The solutions we think of have to work for all of us. Some of the things we've tried have worked well (the new blood pressure protocol), and other's haven't (flowstaff workflow charts, Epic tools and dot phrases, and to an extent, this blog).

We deliberately deferred solving specific problems today. I thank everyone for their patience with "the process" today. Ultimately, as the cluster facilitator, I am responsible for delivering results. The best I could hope to do is deliver your wish list for a good day, every day.

I have my marching orders: a good day, every day, and solutions that work for all of us.

State Pain Management Guidelines

A reminder to all that the Washington State’s Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain is available online and serves as the source of our own pain management/opioid guideline, designed around protecting patient safety.

This Guideline is in response to an emerging epidemic of deaths related to accidental overdose of prescription opioids in Washington State and nationally.

Residential Care

DESCRIPTION

The Residential Care Program (RCP), as part of Nursing Home Services (NHS), provides home visits by nurse practitioners to patients who meet the criteria below.

• The patient remains on the Primary Care Physician (PCP) panel and the nurse practitioner partners with the PCP to provide optimal care.
• The nurse practitioner manages episodic and chronic health problems and has a tool kit of standardized tests and measures such as the Geriatric Depression Scale, Mini Mental, and a falls assessment for use as needed to complete a comprehensive assessment. The nurse practitioner orders diagnostic tests and medications, makes referrals to Home Health and Hospice or other services, and recommends/makes referrals to specialists.
• All clinical documentation is recorded in Epic.
• The nurse practitioner communicates with the PCP via Epic staff messaging and collaborates with the PCP to assure seamless delivery of care and services.

CRITERIA FOR RCP
• Generally, but not exclusively, the RCP patient is a frail adult, over age 65, on Medicare, medically complex, and has been identified by Outreach staff, Care Tracker’s Adult Family Home census, the PCP, or other GH provider as a frequent utilizer of urgent care/ED/acute care.
• Patient is unable to follow up with PCP, i.e., is somewhat homebound, although does not necessarily meet the Medicare Home Health definition of homebound.
• Patient may not have been seen in PC for more than one calendar year.
• Patient may have more than one chronic diagnosis such as CHF, COPD, or Diabetes.
• Patient may have advanced dementia, and be unable to be managed in the clinic setting.
• Patient may live in an Adult Family Home, in a private home, or in some cases in Assisted Living.

CRITERIA FOR RETURNING TO PCP FOR ONGOING CARE (RCP DISCHARGE CRITERIA)
Patient is able to follow up with PCP.

CRITERIA FOR ONGOING SERVICE WITH RCP
Patient has ongoing medical needs, but is unable to follow up with PCP.

HOW TO REFER TO RCP or CONTACT RCP

Send an Epic staff message to "p Nursing Home Services" providing:

(this is a dot phrase waiting to happen)

Patient name and consumer number
Reason for referral
Urgency of referral: within 72 hours within 2 months routine
Current address and phone number for the patient or DPOA

RCP GOALS:
• In partnership with primary care clinics, nurse practitioners make home visits to GH members residing in Adult Family Homes and other residences including the patient’s own home; this service enhances care and decreases visits to the ED, hospitalizations, and SNF stays.
• Improved quality measures, including HEDIS scores.
• Increased end of life planning.
• Patient and family satisfaction with the program.
• NHS and PCP satisfaction with the program.
• NHS nurse practitioner FTE adequate to serve this patient population.
• Increased revenue secondary to improved diagnostic coding.

CORE MEETING Minutes Thursday, January 22, 2009

CORE MEETING Minutes Thursday, January 22, 2009

Topics that were discussed:

8:00- Changes in Staff Core Hours:
1. Core hours will be 8-5:00.
Injection Room will be closed 12:30-1:30
Last schedule Core/Injection Room appointment will be 4:30
Last scheduled wound care will be 4:00
Last Injection Room walk-in will be 5:00
Lunch will be staggered.
Pat will start at 8:00-5:00
Sheila and Bobbie will start at 8:30-5:30
Cindy Sewell will start at 7:45-4:30.

8:15 Injection room:
1. Containers that fit into the refrigerator: we have new containers for the Allergy
Serum, that we will trial.
2. Power failure/procedure to save and transfer medications: (Just a review)
We discussed new containers, labeling and hours that medications can be at room temperature.

8:30 Warm Transfers
1. Follow up from December 6ths meeting- Core staff have not noticed any
Change in the warm transfer of patients. Without the report staff often get
Confused as to why the patient is back in the core. (ABI vs. ted hose, IV
Fluids. Etc) because sometimes 2 core staff will assist with the same pt.
2. We are still in the process of putting together a team who will work on the transfer form

8:40 Wound Care: unable to discuss as we ran out of time
1. Changes in the wound product Formulary- unable to discuss as we ran out of time
2. Cost of Dressings.

TID BIT: Pat and Sheila are experimenting with sugar and wounds. The results so far are
outstanding.

Flow Nurse Chronic Condition Testing Outreach Responsibilities

Flow Nurse Chronic Condition Testing Outreach Responsibilities
East Cluster, Burien Medical Center

For a given patient overdue for hemoglobin A1C, LDL, or microalbuminuria testing, the flow nurse will do the following:

• Open an orders encounter and pend standing orders for all three tests if the patient is diabetic or LDL alone if the patient has heart disease but not diabetes. Choose different intervals depending on the test: Hemoglobin A1C = 12 weeks; LDL & microalbuminuria testing = 26 weeks.

• Create a smart phrase in your personal smart phrase folder that says the following: “.m .lname is due for the following tests: ***. Standing orders already exist for these tests at the lab. Tell patient that .he must go to the lab in order to refill .his medications. .He does need to be fasting.”

Note: there was some discussion about the ability to create standing orders for longer than a year, but according to CIS: "the Office of Inspector General (OIG), Model Compliance Plan requires that the plan of care be reviewed every year," and thus prohibits standing orders beyond one year.

• Locate a chronic condition drug for the patient that corresponds to the kind of test that is overdue. Identify a drug that is most likely to be filled next by looking at the date of the last fill. For example, if a patient is overdue for hemoglobin A1C or microalbumin (tests related to diabetes), you would ideally pick a diabetes drug like metformin or glyburide that will be filled soon. If a patient is overdue for LDL testing, you would ideally pick the statin drug. If there is not an appropriate drug, simply pick a drug that is going to be filled soon.

• Within the orders encounter, re-order the drug (or drugs) that you have identified and label them as “update and file.” When you clicked on the drug itself in order to label it “update and file,” you opened a comments field in the middle of your screen.

• In the comments section, insert the smart phrase listed above, listing the drugs that will need to be completed in the ***. This comments section is always seen first by pharmacy staff when filling a prescription and it will prompt them to notify the patient of the need to get testing done.

Sample Cancer Screening Outreach Letter (Paste in Your Epic Smart Phrases)

Dear .m .lname,

As your personal doctor, I want you to undergo periodic testing to be sure you do not develop cancer. Many cancers are curable if detected and treated early. My records show that you are due for the following cancer screening tests:

MAMMOGRAM: a kind of xray used to identify breast cancer. You may schedule a mammogram on Capitol Hill by calling 206.326.3600. Alternatively, once a month, mammograms are also available at Burien Medical Center and can be arranged by calling 206.901.2400.

PAP SMEAR: an office procedure used to identify cervical cancer. You may schedule a pap smear at Burien Medical Center either with me or one of my colleagues by calling 206.901.2400.

FECAL OCCULT BLOOD TESTING OR COLONOSCOPY: tests used to identify colon cancer. They are equally effective screening tests. Fecal occult blood testing is the least invasive method and should be done yearly. I've enclosed a set of these cards for you with this letter including instructions on how to complete them (on the inside of the envelope). Alternatively, you may do a colonoscopy once every ten years. Colonoscopies are done in the gastroenterology department on Capitol Hill and require anesthesia and a colonic preparation the night before. It is a more involved procedure. A colonoscopy involves a camera being passed through your rectum and into your colon to visualize it in its entirety. If you would prefer to get a colonoscopy, you may schedule it by calling 206.326.3050.

Thank you very much for staying up-to-date with your preventative care.

If you have any questions, please let me know.

Sincerely,

.pcp

.brn

Decisions From East Cluster 1/28/2009

Regarding flow nursing outreach responsibilities in the East Cluster, at today's meeting we decided on the following points:

The one page sheet that summarizes the flow nurses' outreach responsibilities lists a variety of quality indicators that can be organized as to how the nurses will approach outreach.

Immunizations for Children. There is a statewide electronic database (Child Profile) that tracks completion of immunization rates for Washington's children. Becky is presently arranging for several nurses to get access to this database. If this is successful, our first effort at updating immunization rates will involve flow nurses looking up patients listed as behind on immunizations and making sure in the database that they have not already received the immunizations outside of Group Health. For now, this will be the main outreach effort in this category.

Tests (includes A1C, LDL measurement, microalbuminuria testing). Flow nurses will put in standing orders for these tests to be done on all patients who are due for testing. The flow nurses will do two things: 1) pending standing orders; 2) using the update and file feature on a chronic care medication that will likely be filled soon, they will use a dot phrase in the notes section of the pharmacy ordering field to ask the pharmacist at the time of medication pick up to ask patient to get appropriate tests.

Cancer Screening. We will draft a dot phrase letter that alerts patients of the need for mammography, cervical cancer screening, and colorectal cancer screening. Flow nurses will send these letters out to patients in need, deleting the sections that do not apply to them. Our outreach efforts for cancer screening will be limited to these letters.

Of note, in none of the above outreach efforts, are our flow nurses doing cold calls on patients.