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	James L. Holly, M.D.

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Governance Board - Change Existing Processes to Improve Performance

Leaders Implement change in existing processes to
improve the performance of the organization
LD.03.05.01
The SETMA Model of Care

The tracking by each provider on each patient of the provider’s performance on preventive care, screening care and quality standards for acute and chronic care. SETMA"s design is such that tracking occurs simultaneously with the performing of these services by the entire healthcare team, including the personal provider, nurse, clerk, management, etc.
The auditing of performance on the same standards either of the entire practice, of each individual clinic, and of each provider on a population, or of a panel of patients. SETMA believes that this is the piece missing from most healthcare programs.
The statistical analyzing of the above audit-performance in order to measure improvement by practice, by clinic or by provider. This includes analysis for ethnic disparities, and other discriminators such as age, gender, payer class, socio-economic groupings, education, frequency of visit, frequency of testing, etc. This allows SETMA to look for leverage points through which SETMA can improve the care we provide.
The public reporting by provider of performance on hundreds of quality measures. This places pressure on all providers to improve, and it allows patients to know what is expected of them. The disease management tool “plans of care” and the medical-home-coordination document summarizes a patient’s state of care and encourages them to ask their provider for any preventive or screening care which has not been provided. Any such services which are not completed are clearly identified for the patient. We believe this is the best way to overcome provider and patient “treatment inertia.”
The design of Quality Assessment and Permanence Improvement (QAPI) Initiatives - this year SETMA"s initiatives involve the elimination of all ethnic diversities of care in diabetes, hypertension and dyslipidemia. Also, we have designed a program for reducing preventable readmissions to the hospital. We have completed a Business Intelligence (BI) Report which allows us to analyze our hospital care carefully.

SETMA’s quality care improvement is continuous because our tracking, auditing, analyzing and reporting of our performance is continuous. When SETMA’s performance is seen to be less than idea, we instantly begin looking for ways to improve.

HCAHPS Improvement

On July 15, 2013, Drs. C. Deiparine, Qureshi, Anwar, Leifeste, Holly and Brandon Sheehan met with the Baptist administrative healthcare team in a monthly review of SETMA’s performance on inpatient care. The major discussion was around the HCAHPS patient satisfaction survey done by a contractor for Baptist. There was on the part of providers a sense of futility as the standard required is extraordinarily high and the judgment of whether or not a provider meets that standard is totally subjective on the part of the patient and/or patient’s family. Because we deal with an extremely vulnerable population, including a large population of those who have not been part of the healthcare system previously, we find these standards difficult.

SETMA’s goal is to solve this problem in a systemic and sustainable fashion rather than simply try to use gimmicks which are a hit and miss effort. And, it is our goal to solve this problem in a manner which will contribute to the quality of care all of our patients receive. SETMA requested a copy of the content of the standard and that has been given to us. (see the attached) We will review that this morning in our monthly provider meeting. A copy of the attached will be given to each of SETMA’s providers and I will hold a meeting with our hospital care team and review it with them. SETMA’s Seven Step Plan to meet HCAHPS Standard:

Hospital Admission Plan of Care - For almost a year now, SETMA has been producing a document upon the patient’s admission to the hospital which includes: diagnoses, reconciled medication list, procedures, tests, consultations planned for the hospitalization, potential for readmissions and detailed contact information. We are going to make one change. Rather than the hospital staff giving this to the patient, it will be placed at the front of the chart and the attending physician will give this to the patient and explained it to them. For those unfamiliar with this document a de-identified copy of a recent admission is attached above.

The Hospital Care Team will review this document to see how we can strengthen it. We will ask the attending physician to note on the Daily Progress Note after admission that this document has been given to the patient and explained to the patient and/or family.

Notification to the patient of the attending - Our Hospital Care team will be given a script for how to address the identity of the patient’s attending physician. It will say something like, “I am a member of SETMA’s hospital care team and I work closely with Dr. ______, who will be your attending physician for this admission. We know that Dr. __________ is your personal physician but he has asked Dr. __________ to see you during this hospitalization. All of your information will be communicated to Dr. __________ and I and your attending physician has access to all of your medical history and past medical treatment. Don’t hesitate to ask us about your care. We will be happy to explain anything that is not clear. We want your hospital care experience to be a good one.”

For Those Who Round Early - There is a tremendous advantage to the patient for early rounding, but on occasion (over 80% of the patients are awake and eager to talk to the doctor no matter how early he/she makes rounds. There is more frustration for the patient and family when the provider rounds very later in the day - after 3 PM - than when a provider rounds early), the patient is not alert. As a consequence, we will ask all provider who round before 6 AM to make the following statement to the patient AND to document this on the patient’s chart.

“SETMA has a healthcare team who works in the hospital all day to make sure that you get the care you need. That team communicates throughout the day with me (the attending), but because I round early, I know sometime all of your questions do not get answered. Therefore, the Hospital Plan of Care which I have given you has my office and cell phone number on it. If you have a question, call me. If your family or medical power of attorney would like to meet with me, call my office and they will schedule a conference at the office in the afternoon. It is important to me that you and I work together to provide you the best possible care. We start early because we do not want to waste your time and we want all of your care to begin as soon as possible.”

Further Step for Those Who Round Early - When a patient’s care is complex and when the patient is unable to comprehend their care and when others are not present, the attending will ask a member of the Hospital Care Team to return during the daylight hours to explain the plan of care to the patient’s family and to arrange for a conference with the attending if it is desired.

Hospital Care Summary and Post Hospital Plan of Care and Treatment Plan -- Upon discharge, the patient is presented with a copy of their Hospital Care Summary and Post Hospital Plan of Care and Treatment Plan and their personalized Hospital Follow-up instructions. (A copy of that document is attached for the same patient whose Hospital Admission Plan of Care is presented above. In the past 4.3 years SETMA has discharged more than 21,000 patients from the hospital. 98.7% of the time, the Hospital Care Summary and the Follow-up instructions have been given to the patient at the time of discharge.

SETMA’s providers and hospital care team will review this document to make sure that it is complete and a renewed effort will be made to make sure the patient and/or family receives the Follow-up Plan with the following statement, “Dr. ______ has asked me to make sure that you receive this document so that you know exactly what your care is to be. Is there anything you don’t understand and are you able to care out these plans? Dr. ____ has asked me to arrange for you to receive a follow-up telephone fall tomorrow to make sure that you have your medications and understand you care.”

Care Coordination Follow-up Call - Every patient discharged from the hospital receives a 12-30 minute telephone call from SETMA’s Care Coordination Department the day after discharge. They will be instructed to say, “Your attending physician, Dr. ________, has asked me to call you to see if you have any questions about your hospitalization, your medications or your follow-up care.” The Coordination Department will repeat the medication reconciliation and will review all follow-up plans.

Follow-up with Primary Care Provider - If a patient is high risk for readmission, he/she will be seen by SETMA within two days of discharge and if they are not they will be seen by their primary care provider within five days of discharge.

In less than ten days, SETMA produced a tutorial for how to use our HCAPHS program. That can be reviewed at: http://jameslhollymd.com/epm-tools/SETMAs-Internal-HCAHPS-Survey-Tutorial. The following are the links to the entire discussion. Posting this publicly allows others to see what we are doing, including our patients and it allows us to review the process of improvement which we followed:

HCAHPS on weekend call July 20, 2013

The improvement can be seen by the August audit (number 8) and the August-December, 2013 audit (number 9).

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