What does it look like…
As I began to prepare for this presentation, I began to
research, after all, I was asked to speak about this and I
wanted to be prepared!
So here’s a picture of what it
initially looked like for me…
4) Now on to what interprofessional collaboration
can look like!
Interestingly, I had no idea exactly what was in store
I was asked to be part of an initiative, which was
called the Outpatient Quality Improvement
Network or OQUIN …
(OQUIN) was started in 1999
to improve the
cardiovascular health of SC.
At this time SC ranked 33rd
nationwide in CV health.
The goal? Worst to first!
Initially 20 physicians, 3000
2011 - 9000 physicians, 1.94
OQUIN has helped propel
SC to 17th in CV health.
How did they do it?
Collaboration was key!
OQUIN received medical
The data was then analyzed
and returned to the practice in
the form of a ‘report card’.
This report allowed the
practices to monitor the CV
health of patient population
This data was then used to
drive decisions, care, quality
improvements and research.
Quality monitoring at no cost to the provider!
Comparisons to other local and national practices.
Quarterly reports to guide care and improvements.
Assistance with NCQA accreditation and medical home certification
But perhaps most importantly,
Nurses from some of the involved practices were trained in Lean Six Sigma to
assist with research and quality improvement initiatives.
In 2012 OQUIN Announced
This was exciting since:
Catching our clients at a younger age allowed for
more time to intervene and change health habits.
More time to improve their health =
improved health = decreased cost
Ultimately, improved health outcomes for the children of SC
Center of Pediatric
Where it all started…
Did you know…?
one of the largest pediatric ambulatory care centers in the state of SC.
Approximately 18,000 patients
50,000 visits per year
Committed to obtaining PCMH certification
The Tool: Lean Six Sigma
Lean Six Sigma quality improvement methodology
developed Bill Smith and used by Motorola
Variation is the enemy!
LSS levels goto 7
Variation, defects/ million
It follows the steps of DMAIC,
Define, Measure, Analyze, Improve, Control
The first step is look for something broken so you can fix it..
Starting, was the hardest
part! LSS was the guide…
As with anything, starting was the hardest part!
But this is where LSS training kicked in
There were steps to follow to define the problem
A charter was developed
The question was developed
The timetable was mapped out
Team members were selected
The Team: Different Strengths
Project sponsors: OQUIN team
Champions: Tom Moran, Katy Smathers
Liaison: Sabrena O’Connor
ECW: Cindy Garnett
Nursing: Tammy Gladson, Susan
Physician: Doreen Patterson
IT: Daniel Leonard
Team charter is an
important part of define
Team Charter includes:
Business case: So what?
Project Statement: What is broken?
Goal Statement: What is the goal?
Project Scope: What is the start and
end point of the process in question?
Project Plan: Timeline!
Team Members: Who will help and
I was ecstatic when we discovered
we had a problem….!
Not all children were having
their heights measured with each visit…
No height = No BMI
We didn’t know why at this point
and no intervention was planned,
that would come much later..
The voice of the customer (VOC): Business case in charter
Health of the pediatric patients
Clinic’s desire to become a patient centered medical home (PCMH)
Initially, obesity counseling was not reimbursable
The critical to Quality (CTQ): Goal
Diagnose patients with BMI’s greater than or equal to 85%, 100% of the time
for patients aged 2 to 18 years of age.
The charter included a project plan, which outlined projected dates for the
DMAIC steps. A SIPOC mapped the process.
Upon check in the nurse needed to obtain and chart a height and weight as
both these calculations were needed to calculate a BMI.
Once these were inputted into the computer the obesity identification process
So we had defined our
Set goal the goal - 100% BMI
Reviewed the process with a
SIPOC to discover what process
was involved …
Height and weights were
assessed during check in…
So what started the check-in
What ended the check-in process?
Then we begin to
Parameters were set for measurement of the
problem…all children ages 2 – 18 years of
age were to have heights and weights
obtained on every visit.
A baseline measurement was needed so we
met with Daniel in IT to determine which
visits would be included.
The baseline measurement was established
We discovered only 77.55% of the
appropriate visits had BMIs charted,
22.45% of the patients had no BMI
Here is where we had to
Why were we missing data?
Brainstorming and a cause and effect matrix revealed
Nurses were not obtaining heights on triage visits
Misconception that this data was not retrievable for meaningful
So we worked to
The staff was engaged
A presentation of the importance of
height and weight was made
The goal was to obtain heights, as well
as, weights on all children
ages 2-18 for BMI calculation
IT assisted with data collection, before
and after to ensure parameters were the
Process improvement implemented:
Before 22.45% of BMIs missing,
After 1.46% were missing.
We improved! Now how
do we control the gains?
To control the gains:
Being a new investigator,
Starting was the hardest part
but the direction supplied by LSS, OQUIN and a visionary
CPM management team helped.
It was difficult for everyone to see the relevance at first and
in such a busy practice this is understandable
it was through working jointly on the Obesity Initiative
and other projects that understanding and support have
The very act of mutual goal setting and problem solving increased respect
and appreciation for the different strengths, ideas and opinions of each team
Their different roles, goals and perspectives enriched the process
Contacts from within and from without of GHS increased to get the job done.
Ultimately, building rapport and mutual respect.
We started a research project but ended with a interprofessional collaborative
Lastly, there is something
new in Greenville
Recently OQUIN merged with the GHS.
It is now called the Care Coordination Institute.
This is very exciting for our community and for the upstate!