2018 TBC Learning Collaborative Session 3, Aug 01 2018

Welcome!
Implementing Team Based Care (TBC)
Learning Collaborative
National Cooperative Agreement and Community Health Center, Inc.
Session Three
August 1, 2018
3:00 - 4:30 EST

We will begin shortly…
Welcome
2

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TBC Faculty, Collaborative Design, Facilitation
AnnMarie R Hess NP, MS
 Consultant
 ahess@maine.rr.com
National Cooperative Agreement
Amanda Schiessl, MPP
 Project Director, NCA
 Schiesa@chc1.com
Nashwa Khalid, MA
 Project Coordinator, NCA
 khalidn@chc1.com
Kerry Bamrick, MBA
 PI, NCA & Program Director, Postgraduate
Residency Training Programs
 Kerry@chc1.com
3:35
Margaret Flinter, APRN, PhD, FAAN
 PI, NCA & Senior Vice
President/Clinical Director
 Margaret@chc1.com
Mentors, Coaching Faculty
Deborah Ward, RN
 Senior Quality Improvement Manager
 WardD@chc1.com
Kasey Harding, MPH
 Director of the Center for Key
Populations
 HardinK@chc1.com
Evaluation Faculty
Kathleen Thies, PhD, RN
 Consultant, Researcher
 ThiesK@chc1.com

Name of FQHC Coach Position
Central Virginia Health Services, Inc. Lisa Dunkum RN Risk Management Coordinator
HealthRIGHT 360 Alan Hernandez Gutierrez Clinic Operations Manager
Lancaster Health Center
Mark Sprunger
Julie Hoffer
Manager, Patient Services Center
NCMA, Clinical Informatics Specialist
Western Maryland Healthcare
(Mountain Laurel)
Erica Healy
Autumn Rush
RN
PAS Supervisor
New Horizons Healthcare
Angela Martin
Missy Stevens
PNP
LPN
Northwest Michigan Health Services Bree Myers QI Data Coordinator
Optimus Healthcare Nelly Angah Practice Coach
San Vicente Family Health Center
Veronica Belis
Cara Johnson
Patient Access Specialist
FNP
Thunder Bay Community Health Service Kayla Berry Operations Director
Tri-Cities Community Health
Whitney Garcia Fraga
Sara Dusky
Quality and Accreditation Coordinator
Clinical Pharmacist
Wellspace Health Jeremy Meis PA-C
Family Health Center of Worcester Anne Reeder QI Nurse
Ocean Health
Jeremiah Walsh,
Kim Tozzi
Director of Education
Regional Practice Director

Mentoring
 Teaching Skills and Reviewing Tools
 Clarifying Assignments and Rationale
 Addressing Challenges
 Providing Resources (Moodle)
Action Period 2
22 Mentor Sessions
Helping 13 Coaches
2 Sessions Weekly
(Deb and/or Kasey)
9-10 Coaches
Attending Weekly
Mentoring and Coaching Action Period 2

Coach Challenges Action Period 2
 Pacing team members , leading them through steps in process
 Identifying correct scale/timeline for projects. ‘How small is too small?’
 Using data effectively
 Keeping up team momentum
 Picking easy wins within control of team to avoid ‘feeling stuck’
 Coach role and team time – doing vs helping

Thank you for Session 2 Feedback
80%-100%
 Satisfied with how this session met learning needs.
 Content was relevant to their work
 Teaching methods were effective
 Will apply what they are learning their work context
 Enjoyed seeing where other groups are in their work
Improvements
o Spend more time on each content session
o Compare assignments across teams
o Provide more examples how to prioritize one initiative over the
other
o Share what other teams consider best practices

Objectives Session 3
 Summarize Action Period 2 Milestones (6 weeks)
 Discuss MA Role Optimization as key TBC Concept
 Learn from team Specific Aims and PDSAs
 Provide a QI Refresh : PDSAs Methodology and
Measurement
 Provide path forward and assignments for Action Period
3

 Define Core and Extended
Team (structure, roles)
 Achieve multiple TBC specific
aims, data driven PDSAs
 Standardize (SDSAs) roles
and key processes (Playbook,
Spread Plan- another team)
 Improve team and coach skills
(improvement science, team
work, coaching)
 Move Practice Assessment
Data toward Level A
 Develop a post collaborative
team Improvement Plan
Structure and Expectations
Seven 90 min Zoom Learning Sessions
( 3:00-4:30 EST)
Between Session Action Periods (6 weeks)
Weekly Team Meetings, Daily Huddles
Complete Assignments
Upload Your Work Moodle Folders
Online Moodle Learning Network (Share Your Work , Resources)
Between Session
Coaches Meet with Mentors Weekly
Faculty Support
Discussion Board
7
May 9 June 20
Pre
Work
Aug 1 Sept 12 Oct 24 Dec 5 Jan 16
Action Period 3

Team Based Care and Quality Improvement
Core Concepts in Team Based Care Teamwork Gathering and Using Data

Session 1 : May 9 2018
o Running effective team meetings using tools
o Developing a cause and effect diagram to inform PDSAs
o Writing a global and specific aim statement
Session 2 : June 20
o Developing a process map or current state workflow
o Applying PDSA methodology for improvement
Session 3 : Aug 1
o Using data for improvement (run charts, control charts)
Session 4 : Sept 12
o Standardizing (SDSAs) and Reliability Science
Session 5 : Oct 24
o Spreading Change
Session 6 : December 5
o Gantt Charting : 3-6 month Core Team improvement plan

Implementing Team Based Care (WEBINARS 2016 and 2018)
→ Defining your Core and Extended Team Structure
→ Strategically redistributing work among team
members
→ Increasing communication among the team, practice,
patients.
→ Creating new responsibilities and provide training
→ Improving efficiencies (cycle time, duplication of
effort, EHR)
→ Standardizing processes to reflect new model
(making hundreds available)
→ Using a plan for optimizing the model
→ Meeting Regularly, Huddling Daily

Time Learning Session 3 Agenda Lead
3:00 Welcome and Introductions Amanda Schiessl
3:05 Objectives and Agenda
Action Period 2 Milestones
Ann Marie Hess
3:15 Role Activity Analysis : Team Insights Family Health Center of
Worcester
3:25 TBC Concept : MA Role Assessment and Optimization Mary Blankson, CNO CHCI
Team Discussion
3:45 TBC 7 min presentation, 3 min questions
 Team Optimus : Hypertension Aim
 Team WellSpace : Diabetes Aim
Team Member
4:05 QI Refresh
 Applying PDSA methodology
 Using data for improvement
Deb Ward
Kathleen Thies
4:20 Action Period 2 Assignments Kasey Harding
4: 25 Wrap Up Amanda Schiessl

Action Period 2 Assignments
1. Work on Weekly Meeting Challenges
2. Improve Your Daily Huddles and Standardize
3. Revisit Your Communication Plan
4. Continue with Action Period 1 Assignments
5. Write a Specific Aim aligned with Global Aim
6. Complete a Process Map of the workflow you want to improve
7. Brainstorm ideas for achieving your aim , do some Benchmarking
8. Plan your PDSAs , Implement Some Tests of Change

Assignment
No. Of Teams that
have completed the
assignment
N(13) %
Daily Huddles 13 100%
Role Assess 13 100%
Cycle Time 13 100%
Global Aim 13 100%
Fishbone Diagram 8 62%
Specific Aim 10 77%
Process Map 6 46%
Started PDSA 2 15%
Progress Action Period 2 Assignments
Please upload to Moodle so we can help and provide
feedback

Process Working On Specific Aim Better Measures
Breast Cancer Screening
Mt Laurel
We will increase the percentage of Mammo
screening rates for female patients age 52-72 and
3 office visits within the last 3 years with all
Oakland providers by 8 percentage points, from
67% to 75% by 10/06/2018
Cervical Cancer Screening
Central VA
We will improve the number/amount of Cervical
Cancer Screening by 75 women by 12/31/2018.
Cervical Cancer Screening
HealthRight 360
We will increase the percentage of cervical cancer
screenings by 3 percentage points by the end of
August 2018.
Hypertension Control
Optimus
We will improve the percentage of hypertension
patients by 2 percentage points by July 29th, 2018
HbA1c Collect Diabetes
WellSpace
We will decrease the percentage of patients
empaneled to Jeremy Meis PA-C MPH or Gian
Pinot, MD with a diagnosis of type II diabetes and
no A1c checked in the last year from ~32% to 10%
by December 31st
, 2018.
Diabetes Control
Centro San Vicente
We will decrease the number of Dr. Celina
Beltran’s, Christina Paz’s, and Maribel Gonzalez’s
known diabetic patients with a HgA1c > 11%
between 02/2018 and 05/2018 from 25 to 7 by
12/01/2018.

Process Working On Specific Aim Better Measures
Cycle Time
Pre Visit Planning
Tri Cities
We will increase the number/amount of daily
patients prepped prior to visit continuously from
0% to 60% by September 1, 2018
Cycle Time
Check In, Late Patients
Lancaster
We aim to decrease the total cycle time from the
current average (greater than 1 hour, 20 min
appt) to 50 min) by 10/31/18.
We aim to decrease percentage of late patients
by 6% from the current amount (311 total late
patients Water St site past 2 months) to 291 late
patients by 10/31/18 (20 patients).
We aim to decrease amount of wait time during
check in due to billing issues.
Cycle Time
Appointment Scheduling
NW Michigan
We will Increase the number of patient
appointments /day from 10.4 to 14.4(Lisa) and
7.86 to 11.86 (Marisa) by July 16th, 2018
We will increase the percentage of patients very
satisfied by 25% from 59% to 74% by July 16th,
2018
Self Management Support
Ocean Health
We will improve the quality of patient experience
and clinical workflow by improving patient
compliance with follow up care, leading to a
more meaningful encounter and an increase in
the patient's quality measures by 9/15/2018.

Lancaster
Time Consuming EHR Documentation
Lack of Pre Visit Planning
Late Patients
Late Staff (AM, PM start times)
Inconsistent
Rooming Standard
Implementation
Long Lines Front (billing)
 High Leverage
 Control of Team
 Start Small, Scale Up

Central Virginia
Health Services
UDS 37%
75 Women
Fishbones
• use data
• label bones with very specific causes of problem
(hysterectomy documentation) , avoid solutions
• look for quick hits, just do it (posters exam room)
• take time analyzing EHR documentation and
reporting issues

Sharing Best Practices : Action Period 3

Defining Core Team (PODs and Teamlets)
“patients want small teams that they know personally”

Extended Team (think about - do these people interact with patients?)
• CMO
• QI
• Provider
• BHC
• NP
• LPN
• Dir Patient Care Coordinator
• MA
• RN
• Nurse Manager
• PSR
• LCSW
• Chemical Dependency Coordinator
• Phlebotomist
• LMSW
• CHW
• PharmD
• CSM
• Front Desk
• POD Leader Call Center
• Health Educator
• Referral
• Tracking
• Patient Navigator
• Medical Records
• Billing
• PAR

Action Period 2 Milestones
Ann Marie Hess
Worcester
3:25 TBC Concept : MA Role Assessment and
Optimization
Mary Blankson, CNO CHCI
Team Discussion
Team Member
4:05 QI Refresh
Deb Ward
Kathleen Thies
August 1, 2018 3:00-4:30

Family Health Center Worcester

FAMILY HEALTH
CENTER OF
WORCESTER
Role Tracker
Assessment Tool
1. August 2018

PROCESS
Initially sent tracker to each team member for individual
work
Came together over multiple meetings for
discussion/completion of tool
Completed the tracker twice:
1. Who is currently doing the process?
2. In a perfect world, who would be doing the process?

INSIGHTS
Learned that some tasks are not being done by anyone: For
example - no one is documenting social determinants of health in the
history section for every patient.
Some duplication of tasks across roles makes sense, some do
not: Sometimes duplication of tasks make sense from a patient safety
perspective. For example, it makes sense that both Behavioral Health and the
Primary Care Teams be able to provide support in a behavioral health crisis or
that multiple people would be able to educate patients on medication safety.
Operationalizing “top of license” practice is hard, doesn’t
always come naturally
Short-staffing can make it difficult to assign tasks
appropriately

NEXT STEPS
Fishbone Diagram
Process Map
Specific Aim

Comparison: Role Activities
C: Who is currently doing this
B: Who is the best person to do this

https://www.weitzmaninstitute.org/NCA
Advancing TBC Core Concept Resources
2016 Webinars
#1 Advancing Team Based Care : Building Your Primary
Care Team to Transform Your Practice
#2 Enhancing the Role of the Medical Assistant
#3 The Emerging Role of Nurses in Primary Care
#4 Data Driven Dashboards to Support Team Based Care
#5 A Team Approach to Prevention and Chronic Illness
Management
#6 Complex Care Management in Primary Care
#7 Achieving Full Integration of Behavioral Health and
Primary Care
#8 Dissolving the Walls: Clinic Community Connections
2018 Webinars
#1 Taking Team Based Care to the Next Level
#2 Advancing the Practice of RNs and
Behavioral Health Providers
#3 Beyond the Walls: Effectively Utilizing
Community Health Workers and Clinical Home
Visitors as Part of the Team
#4 Caring for Patients with Pain
is a Team Sport
LEAP Project
Improvingprimarycare.org

MA Involvement in Key Functions or Competencies
Track, identify,
and reach out to
patients with
care gaps
Population
Management
Provide patient-
centered,
evidence-based
services
Planned Care
Self-
management
Support
Medication
management
Behavioral
Health
Integration
Provide follow-
up and care
outside the
office
Care
Management
Referral
management
Clinic-
Community
Connections The
Quadruple
AimsCommunication
Management
Enhanced
Access
Meet patient
needs in a timely
manner

Team Practice Assessment: How Do We Shift Levels Toward A?

Newer Roles for MAs
Pre-visit planning
36
Reconciling medications
Scribing for providers
Participating in quality improvement work
Health coaching and motivational interviewing
Delivering or arranging preventive services
Providing telephone or in-person follow-up

How do effective practices
deliver planned care?
Identify the key
clinical tasks
associated with
evidence-based
care and decide
who does them.
MA reviews
patient data prior
to the encounter
to identify
needed services.
Encounters are
organized so
that relevant
team members
deliver all
needed care.

How do effective practices manage
medications?
• Medication reconciliation is viewed as a critical
intervention for both patient and practice—often
begun by MA at intake.
• Pharmacists and RNs play important roles in
complex med. rec., titrating medications, and
addressing non-adherence and other drug problems.

How do effective practices deliver planned follow-
up and Care Management
(outside of visits)
• Follow-up between office visits is a core function of the
practice team.
• Care teams regularly monitor patients and promote self-
monitoring.
• Follow-up can range in intensity from periodic status
checks by telephone or e-mail (MA) to active care
management (RN).
• Higher risk patients (poor disease control, frailty, etc.)
receive regular follow-up (monitoring) AND active care
management.

Discussion Questions
1. What are the exact hours that MAs work?
2. Do the daily team huddles follow a specific flow? If so,
what is it?
3. Do you provide time for MAs to do both panel
management AND pre-visit planning? Or do you treat
these processes as one in the same at CHC?
4. Where does panel management work happen? In the
pod? Or elsewhere?
5. What does the process of MAs checking for vaccines and
Rx refills look like? How long does it typically take per
patient?
6. How do patients check out after visit? Do they do so in the
room with the MA? Or at the front desk?

Diagram for Improvement Process
Specific
Aim
1
PDSA with
Measurement
PDSA with
Measurement
PDSA with
Measurement
Global AIM
Specific
Aim
2
PDSA with
Measurement
PDSA with
Measurement

OPTIMUS
Developing core and extended team capabilities for implementing an advanced team based care model.

CHC, Inc. Care Team
Transformation Project
Jennifer Gilbert, DNP, APRN,
RN Care Team Presentation
08/01/2018

Global Aim
•We aim to improve our
Hypertension rate for patients
with uncontrolled
hypertension at our Barnum
site.

Data used to Define the Problem
•UDS Measure: % of patients with HTN
who have BP less than 140/90.
• HTN Control Rate over time for Gilbert
Team

Specific Aim Statement
•We will improve the
percentage of hypertensive
patients in control by 2%
points by July 29th, 2018 (for
Gilbert’s panel).

Measure- Baseline Data – Current
Data
Baseline Current

Potential PDSA based on Process Map(Suggestion
from CHCI team)
• Referral to Care manager
• Enhance education materials
• Follow-up

OPTIMUS HealthCare
40 years of Caring
Bridgeport Stamford Stratford Milford
QUESTIONS?
THANK You!

WELLSPACE
Developing core and extended team capabilities for implementing an advanced team based care model.

Global Aim
We aim to improve glycemic control in WSH patients
with uncontrolled DMII at WSH Alhambra health center.
The process begins with identifying patients with
uncontrolled DMII (A1c over 9%) or no A1c checked in
the last 12 months and ends with adequately
measuring and achieving glycemic control.
By working on the process we expect to decrease
morbidity, mortality & hospitalizations related to DMII,
empower patients, improve health literacy and
awareness, improve our internal processes and
improve the health of our community.

Data used to define the problem
• UDS Report
o Denominator: ALL patients with history of DMII
diagnosis who have been seen
o Numerator: Patients with A1c >9% OR no A1c
checked in the last 12 months.
o Our initial result: 42.7%
• 13% with A1c >9% and the rest no A1c in the last 12 months.

Click to edit Master title style
• Click to edit Master text styles
o Second level
• Third level
o Fourth level
• Fifth level

Baseline Data
• A1c >9%: 24.13% (69 patients of 286)
• No A1c in >12 months: 20.97% (60 patients of 286)

Specific Aims
Specific short term Aim #1:
We will decrease the percentage of patients empaneled to Jeremy Meis
PA-C MPH or Gian Pinot, MD with a diagnosis of type II diabetes and no
A1c checked in the last 12 months from 21.05% (60 patients of 285) by
10 patients by August 31st, 2018.
Specific short term Aim #2:
We will decrease the percentage of patients empaneled to Jeremy Meis
PA-C MPH or Gian Pinot, MD with a diagnosis of type II diabetes and last
measured A1c >9% from 23.86% (68 patients of 285) by 5 patients by
August 31st, 2018.

Process Mapping:
Process begins with identifying diabetes
 schedule visit  chart prep 
visit  education  medications/labs.
Process ends with diabetes measured
and controlled.

PDSAs:
#1: Health Educator
• 1 on 1 meeting with trained MA to perform POC A1c,
urine dip, medication reconciliation and diet and
exercise assessment/coaching
#2: Medication Reconciliation
• Comprehensive Program to increase the chances of all
patients with A1c >9% bring all medications to each and
every appointment
#3: Addressing Patients who are lost to follow-up
• Monthly generation of lists of patients with diagnosis of
DMII and no A1c checked in the last 12 months.
• Contacting patients and ordering labs/scheduling as
appropriate
• Contacting empanelment team when applicable

Hess.CPM.2010
# visits room prepared/
# visits
% visits on time start
8am and 1pm
Daily 10 min
standards
EHR %
complete

Using Data for Improvement
National Cooperative Agreement and Community Health Center, Inc.

Team &
Roles Defined
Assessment
And
Baseline Data
Global Aim
Problem
Statement
Specific
Aims
And
Measures
Change Idea
Solution-
Storming
PDSA
SDSA
Spread
Measure
and
Monitor
Learning
Session 2
Learning
Session 3-5
Learning
Session 6-7
You are here!
Powered by Weitzman
Institute
Core Concepts in Team Based Care Teamwork On-Going Data Collection & Review
Learning
Session 1
May 9

Types of data
Process data: number or
% screened and documented,
cycle time components
Outcome data: % pts with
diabetes A1c<9
Structure: core and extended team
Care Delivery processes: have a beginning and an end over
which you have some control; care delivery; e.g., screening,
cycle time

Most of your data is counting ratio data
• Ratio data are raw numbers with a natural zero, and s
can be multiplied and divided.
– You can have zero lbs.
– 10 lbs is two times heavier than 5 lbs: 5X2=10
– 5 lbs is half of 10 lbs: 5/10=50%
• You count numbers (ounces)
• You measure amounts (quarts)

A good aim asks:
What do I want to accomplish and how will I know it
when I do? Or don’t?
A good aim has measures that are clearly defined.
 If you can’t define it, you can’t measure it or explain
it.
Definitions: who, what, when, wheremeasurable
 Numerators, denominators
Is there a standardized definition, eg, UDS?
 Is your data being collected based on that
definition?
Good measurement

Good data collection plan
 Aim
 Baseline data
 Target
 Definition
 Tool
 Numerator
 Denominator
 How collected
 When/how often
collected: daily?
Weekly?
 Who collects it
 Who aggregates it and
reports it
 When report is due

Aim: We will improve the number/amount of Cervical
Cancer Screening by 75 women by 12/31/2018.
Important? Yes.
Process: Documentation of screening
Clear? No. Need better definition.
Doable? Not sure yet. Strategy? Staff? Time? Is 75 a lot?
How will you know?
Example 1

Aim: “We aim to increase the number of women with
documented cervical screening from X in Quarter 2 2018
to X+75 for Quarter 4 December 31, 2018.”
Who: Women with documented cervical screening.
Who: Patients enrolled in the clinic based on at least one
visit within the past year.
What: Cervical screening [standardized definition]
When: Yearly appointments? Is this the right time frame,
comparing quarterly data?
PDSA: Multiple approaches, use small numbers
Better….

Examples 2 and 3
Aim: We will increase the percentage of Mammo
screening rate by 8% (from 67% to 75%) by 9/3/2018.
Aim: We will increase the percentage of cervical cancer
screenings by 3 percentage points by the end of August
30, 2018.
Important: Yes.
Process: documentation of screening
Clear: Sort of….
Doable: Not sure yet.
Note: an increase of 8% from 67% = 72.6% [1.08X67]

Better
Aim: We will increase from 67% to 75% the percentage of
women patients ages X to Y in X’s panel with documented
yearly mammogram screening between Date and 9/3/2018.
Aim: We will increase from X% to X+3% the percentage of
women patients ages X to Y in X’s panel with documented
yearly cervical cancer screenings between Date and August
2018.
Who: Need to define one panel if you can, clarify that these are
women enrolled in clinic, age range consistent with
guidelines.
What: Standardized definition
When: Routine visits? Right time frame for comparisons?
PDSA: What care delivery processes will you address in order
to do this? What number of patients do the percent increases
represent?

Example 4
Aim: We aim to decrease the average amount of total
cycle time from the current average (greater than 1
hour) to 50 minutes by 10/31/18.
Important: Yes.
Process: cycle time or better, one of its components
Clear: Almost; is there a clear definition of cycle time?
Doable: Not sure yet.

Better
• Aim: We aim to decrease the average minutes of total
cycle time from X minutes to 50 minutes between
8/1/18 and 10/1/18.
• Even better: We aim to decrease the average minutes
of [e.g., check in time] from the current X minutes as of
DATE to X minutes between 8/1/18 and 10/1/18.
• Who: choose all visits or by provider?
• How: how will you get this data?
• When: is this the right time frame? When is baseline?
• PDSA: narrow down to the part of cycle time that is a
problem

 Display aligns with the objective: percent increase or decrease
 Well-labeled X-axis and Y-axis that correspond. What are the
data points? Raw numbers? Minutes? Hours? Percentages?
Intervals? Is the X axis dates? Providers?
 Bar graph illustrates side by side comparisons: can be at a
point in time or by individual units (providers, clinic sites);
can be stacked
 Pie chart takes a whole (100%) and breaks it into parts:
numbers or percentages
 Run Chart illustrates variation over time: days, weeks, months
 Includes interpretation that answers a question
Good display

Example of pie chart
MA Role Activity Tracking
Confusing display: Min? %? 0? Five
activities listed but six pieces of pie
Better: Could also label as percentages

Visits = patients who meet
criteria in the definition of
the measure, i.e.,
denominator
Screened = numerator
% Screened =
Screened/Visits
% at risk = positive
screen/?
Date Visits Screened At risk % screened % at risk
Oct-15 51 22 5 43%
Nov-15 28 16 3 57%
Dec-15 29 29 10 100%
Jan-16 98 42 16 43%
Feb-16 93 48 23 52%
Mar-16 97 44 11 45%
Apr-16 118 107 28 91%
May-16 97 94 18 97%
Jun-16 83 75 17 90%
Jul-16 77 74 7 96%
Aug-16 132 122 8 92%
Sep-16 129 119 7 92%
Oct-16 144 129 9 90%
Nov-16 119 100 15 84%
Dec-16 122 98 13 80%
Jan-17 113 102 15 90%
Feb-17 101 92 15 91%
Mar-17 136 127 13 93%
Apr-17 140 130 13 93%
May-17 139 127 5 91%
Jun-17 73 68 9 93%
Median
screened = 94.00
Average
screened = 84.05
Actual screening data

Example of display:
same data—
Look at Y axis intervals
Data in a bar chart over time

Same data in a time plot: data intervals over time

Two Types of Variation
• Random (common cause) variation
– or “business as usual”
– typically due to a large number of small
sources of variation
• Non-random (special cause) variation
– “something different is happening”
– special or unusual circumstances
– requires interpretation by those who
understand the context
85

86
Anatomy of a Run Chart:
Time can be days, weeks, months, quarters
Y is what you are counting
Variable “y”
Time
Center line is MEDIAN

Run chart of number screened: using Median
A “run” is one or more consecutive points
on the same side of the median; points on the median do no count
20 data points,7 runs

Source: Perla, Provost, and Murray. BMJ Qual Saf. 2011;20:46-51
88
Table. Runs Rule Guidance
Number of observations excluding points
on the median
Lower limit for the number of
runs
Upper limit for the number
of runs
13 4 11
14 4 12
15 5 12
16 5 13
17 5 13
18 6 14
19 6 15
20 6 16
21 7 16
22 7 17
23 7 17
24 8 18
25 8 18
26 9 19
27 10 19
28 10 20
29 10 20
30 11 21
31 11 22

How to recognize Non-Random Patterns
• The presence of a shift in the process
– A run that is too long (6 or more consecutive points
on one side of the median)
• The presence of a trend
– A run with consecutive increases or decreases in
data (5 or more consecutive points)
• The presence of too much or too little
variability
– Too few or too many runs (depends on number of
points on the chart)
89
Perla, Provost, and Murray. BMJ Qual Saf. 2011;20:46-51

21 data points, but one on Median: 20
7 runs, two shifts, no trends

• Interpretation is always in context
– First shift is when they were first collecting data, so
wouldn’t put too much stock in it
– Second shift: what was happening that was
different? Was it something YOU did? Outside
circumstances?
• Shifts and trends are statistically significant
• But statistically significant and clinically
significant in terms of your program or services
are two different things
Interpretation

References
• Nelson, E. C., Splaine, M. E., Plume, S. K., & Batalden, P.
(2004). Good measurement for good improvement
work. Quality Management in Healthcare,13(1), 1-16.
• Perla, R. J., Provost, L. P., & Murray, S. K. (2011). The run
chart: a simple analytical tool for learning from
variation in healthcare processes. BMJ Quality &
Safety, 20(1), 46-51.
• Provost, L. P., & Murray, S. (2011). The health care data
guide: learning from data for improvement. John Wiley
& Sons.

Action Period 2 Milestones (include
comparisons)
Ann Marie Hess
Worcester
3:25 TBC Concept : MA Role Assessment and
Optimization
Mary Blankson, CNO CHCI
Team Discussion
Team Member
4:05 QI Refresh
Deb Ward
Kathleen Thies
August 1, 2018 3:00-4:30

1. Meet weekly as a Core Team
 Practice effective meeting skills using tools, with coaching support
 Use improvement science to implement team based care delivery
 Share your progress with managers and leaders
2. Implement Daily Huddles and Evaluate
 Work on improving (PDSAs) and standardizing (SDSAs)
 Evaluate Huddle impact on cycle time (efficiency), closing care gaps
3. Write ‘better’ specific aim(s) statements , using data and fishbone diagrams
 Small tests of change focused on bones of fish within team control
 Weeks not months to see a change (momentum)
 Easy to measure, meaningful and relevant

4. Implement PDSAs (small, measurable, rapid)
5. Share your work (drafts and final dated versions) upload to Moodle folders
6. Use Moodle resources for brainstorming and benchmarking
 Discussion Board - ask for help and best practices from participants and
faculty
 TBC Model Folders (e.g. Pre Visit Planning Thunder Bay)
 Webinars – 2018 Advancing Team Based Care
7. Session 4 Prep : Volunteers to Share Your Aims, PDSAs , Change Ideas,
Measures

Looking Ahead
Session 4
 Teams Sharing (volunteers)
*Aims, Measures, PDSAs
 Advanced Team Based Care
Concepts and Best Practices
*What You Want to Learn
Team Practice Assessment
And Model Domains
# Teams
Level A
Behavioral Health Integration 8
Enhancing Access and Efficiency 7
Clinic-Community Connections 6
MA Role 4
Medication Management 4
Communication Management 3
Care Management 4
Layperson (CHW, Navigator) 3
Pharmacist 3
Referral Management 2
RN Role 2
Self Management Support 1
Population Management 1

Thank You All!
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