Dr. Alix Casler: A Quality Improvement Success Story

Dr. Alix Casler: A Quality Improvement Success Story


Hi, I’m Dr. Alex Cassler. I am a practicing pediatrician in Orlando Florida. I practice with Orlando Health Physician Associates and I’m here to talk to you today about how our 11-12 office multiple pediatrician practice improved our HPV vaccination rates. I want to start by just talking a little bit about why this is an issue and how poorly we’ve done up until now with HPV vaccination rates in general in the United States. We’ve got this great vaccine yet for some reason rates have not increased as dramatically as they should have. If you read some MMWRs for some light reading which I do, I think it’s fascinating, you can see where we’re falling short and you can see where we could be preventing multiple, multiple cancers in our patients. So when you look at the issue, which is, we’re not doing a good enough job and you say well how are we doing as a group and realize that you’re probably just as good as all of your colleagues which is not adequate. You need to look at how you’re going to approach this and there are some critical components of a vaccine implementation project or vaccine improvement project. First of all, you have got to have a set goal or an aim that means how are you going to do, by when, what changes do you want to implement and then you also have to be able to measure those, you need data. It’s really interesting because in our practice, just like probably every other practice out there, we thought we were doing well, we’re great vaccinators. We needed to sit back and look at our rates and then realized that we had work to do. Decide how we were going to get there which is really your implementation. What are you going to do to fix what’s not working and then put that into practice in a way that is fairly simple and inexpensive. We’re already very busy, we already have lots to do, something that you can scale from office to office to office and something that you can keep going or sustainability. So here we were, this was 2013 when we took on this project. At that time, we had 22 pediatricians in 11 offices. We were part of a much larger multi-specialty group practice with almost 100 employees in the pediatric department. We took care of almost 25,000 patients who are eligible for HPV vaccination and had already really gone through the multiple steps of becoming a level three NCQA certified patient-centered medical home. For what it was worth at the time, I don’t know that we really appreciated how superb that patient centered medical home structure is for delivering optimal care, but our vaccine initiative actually took advantage of some of what we had already done and actually made us a better medical home as well as better vaccinators. We had to start out by looking in the mirror, and I think every group does, we really thought that we were excellent pediatricians and therefore excellent vaccinators until we looked at our rates and I brought those rates to a department meeting first in a blinded fashion in other words here’s how we’re doing as a department in the second half of 2013 and lo and behold we were right there with the rest of the state of Florida. I think we were about number 49th in the country out of 50 states, not so good. We then agreed that along with all of our other disease state metrics, asthma management, flu vaccines, etc., we were going to become transparent to one another with our vaccination rates. We reviewed them monthly at department meetings for a while thereafter and ever since then we review all of our metrics including our vaccination rates on a quarterly basis. This is a little bit of peer influence, a little bit of pressure, a little bit of competition. Also ends up being a little bit of support, “Hey you’re doing really Great.” “What are you doing that’s working so well?” “Can you help me?” It really I think pushed us all to do a better job. We then had to set some very specific goals and this is evidence based, this isn’t just us inventing a process. The process of quality improvement really, really clearly has shown that you need to know where you stand and then you need to decide where you’re going in order to do better. So we decided that the end of that year we were just going to try to do better. We didn’t know what to do with those last few months but we knew that moving the needle was going to make us feel better that our process was underway. We set very specific goals for the end of 2015 that all of our patients 13 through their 18th birthday which correlated with the National Immunization Survey Team so we had something to compare to at the national level. We wanted to be at the national average from 49th in the nation. By the end of this year 2017 we’d actually like to be at healthy people 2020 goals for our entire population. It’s kind of a big goal but so far we’re on track to probably get there. We then decided how we were going to move the needle and we put together what is sometimes talked about in improvement science as a coordinated portfolio of interventions. So that went from just data cleanup, are these really still our patients, who are we looking at. Some very focused education for providers and staff which, I’ll get to because I think that that was very very important, certain pieces of our patient centered medical home process like pre-visit planning, scheduling subsequent appointments which had to do with follow-through and serious completion as well as some order sets and clinical summaries again part of our patient centered medical home initiative in the first place. We ended up using all of these bits and pieces in our process. The first thing we did actually was to do a physician education program and it’s always said in quality improvement that education doesn’t work and and we know that you go to a CME program it’s fascinating, you’re interested in so much stuff, you take all these notes, you pick up all these handouts and then they end up in a file somewhere. So we knew that that wasn’t going to be the be-all and end-all, but we are faced with tremendous number of things that we need to do and HPV was maybe just not that important to a number of my partners so we really needed to sit together and and relearn why this was important. We also educated our staff, they’re part of the team, they’re part of the message, they’re part of the workflow and they can actually achieve things that we as physicians, nurse practitioners, PA’s sometimes can’t in getting through to a family. What we found was that the same things held true for the providers. As for the staff which is we have a lot on our plates competing priorities are huge we have so many metrics that we have to meet that we had to move HPV up near the top of the list by realizing that the disease is common and the consequences are very serious and thus the recommendation by the ACIP that we should be vaccinating at eleven to twelve had a reason and needed to be part of our process. We also had to get past the discomfort of talking about this vaccine and we spent some time with scripting, how do I say it, how do I present this vaccine in a way that’s comfortable and easy and fits right into my pre-teen recommendation ? So we practiced something like this: “Today we have three vaccines to do. The first, prevents a bacterial infection that if you get it, which it’s really, really rare so you probably won’t but if you do, it causes a very serious meningitis which can be deadly. That vaccines sometimes causes an achy muscle in the arm, you might feel a little under the weather for a day and that’s about it. The second one, prevents infection with HPV which is a very, very, very, common virus unlike the rare meningitis. Most HPV goes away by itself, we know that, but a fair amount can go on to cause cancer later in life. That’s a 2 vaccine series we give the first one today the second one is six to 12 months from now. That one could also cause a little bit of an achy muscle, maybe feel a little under the weather today and then the last one is the one that everybody knows about because it’s required for school everywhere which is the Tdap. Which will keep you from getting tetanus if you step on a rusty nail, it’ll keep you from getting whooping cough hopefully, which is a really unpleasant cough for you, you might cough for two or three months but the big thing is we want to prevent you from catching whooping cough so you don’t spread it to someone else and someone else’s baby might die from whooping cough. That one could also cause a little bit of an achy arm, make you feel a little under the weather, you could take a couple of ibuprofen you’ll probably feel fine. Do you have any questions?”. Practicing that scripting was critical for our partners and for our staff in it providing that clear recommendation that this is what we want you to do today. Another thing that we did which was on that list of the portfolio, was to provide tools within each of the offices and each office during their staff education program chose what they thought would work for them. Some of the most popular ones were the reminder magnets which I guess we don’t have anymore but they worked really well for us for a while. The QR code scan thing so you get a text reminder about your next dose too, has been shown, again, evidence-based, this has been shown to be effective especially if the text goes to the teen’s phone. We provided our staff with resources in terms of where to refer parents for good information, the CDC website, straightforward excellent information and also it was a good place for staff to go to practice their responses to questions and for physicians to go to practice their response to questions as well. We did provide some incentives and it’s really interesting what motivates people. Competition was the biggest one so again we were transparent with our rates and for people to hear at our department meeting month after month who had moved the needle the most, which office had done the best was actually one of the best rewards that we could have given. We did provide some little tiny tangible prizes if you will for the first six months or so to the offices that moved the needle the most and our quality bonus now which is really part of that move from fee-for-service to fee -for- value started training us that ultimately we are going to be paid based upon how well we take care of our patients not just how many patients we see, so our quality bonus included credit for our HPV vaccination rates. As part of our patient centered medical home we had gotten pretty serious about pre-visit planning and I just want to tell you at pre-visit planning, to me, is one of the simplest ways to guarantee that patients don’t leave your office with care gaps left open whether that’s depression screening, whether it’s smoking screening, whether it’s a fluoride application for a younger child or whether it’s particular vaccines including HPV, including flu vaccine, including second doses or third doses of series. For us pre-visit planning is as simple as five minutes in the morning. Someone, in my office, it’s me and some of our offices it’s a staff person, going through the schedule and literally making a written document that has everything that needs to happen for each patient that’s on the schedule for the day. That becomes a team working document so that every person who has contact with that patient knows what should be done before the patient leaves. That’s one of our most valuable interventions and it was free. We did build some electronic order sets into our EMR and unfortunately for us, our EMR doesn’t actually have built-in clinical decision support. If yours does that’s even better but we tried to stream line what needs to get ordered for the health maintenance visits including orders for the follow-up visits for subsequent doses so originally it was always for the second dose in two months, the third dose in six months now we actually have built in second dose in six months for patients who are vaccinated. I like to say on time those patients who are vaccinated at the 11-to 12–year-old visit those order sets have actually just facilitated getting everything done quickly, checking the boxes as you need to check the boxes and also not leaving something undone or forgotten. Subsequent doses are also always scheduled before the patient leaves the office. This has multiple, multiple purposes. One is, it’s part of the clear recommendation. It is not just important that you get vaccinated today, it’s important that you finish the series. That’s part of the message, it’s part of the psychological contract with the parent. The second is, if they don’t come we know it was a missed appointment, right, if that stays on the book they also get a phone reminder I guess I got that a little out of order but it works. A phone reminder goes to them reminding them of their appointment. If they cancel the appointment our secretaries know what HPV is, they know how important it is, so they know to reschedule that appointment. It’s not just “oh okay that’s fine. call us back when you have time.” It’s “can I reschedule that for you today?” This meant that we actually had to open our schedules out longer. Most of us our schedules were open three or four months into the future. Now we maintain our schedule six ,12, sometimes even more months out into the future so that appointments can be scheduled. It’s that Important. That then prints on the clinical summary so the parent has a written reminder of (a) when their appointment is and (b) how important that is. So obviously I’m here talking to you because we did a pretty good job and I’m actually very proud of what we’ve done in our group. We started as you can see from this graph with rates that were pretty low and again we thought we were good until we looked at how we were doing and realized that compared to national rates we really weren’t. So if you look at the purple line we’re looking at female patients ages 13 through their 18th birthday which compares to the National Immunization Survey teen data and you can see where national rates were compared to those are the little stars compared to our rates where we started way below national rates ended up right where we wanted to be at the end of 2015 with rates over the national average and and our rates have continued to climb way faster than national averages. Same thing as you move on down looking at males who started their series looking at females who completed the series which at that time again was three doses and then finally males who have completed their series is the little lower blue line. So we have thus far really met our 2015 goals and I think are on track to meet our end of 2017 eighty percent goals to equal healthy people 2020. So we’re now a couple of years into this project actually more than three years and to keep things going we did do sustainability meetings and you could see that on that last graph and the very very latter part of the project we went back into the offices. We figure people forget, people get new priorities, they move on, things get stale, we hire new staff, we had to get back into the offices and remind people of why the HPV vaccine is very, very important, why it needs to remain a priority, refresh their tools, refresh their scripting, fill them in on how they’re doing, see if they needed help with anything. This was really simple. It cost us an hour of overtime per office. A couple of years, again after we had started the original project, it cost us buying pizza lunch for staff but it really re-energized the process and we’re going to do sustainable sustainability meetings for each of our quality metrics in each of our offices from here on out. We also have a couple of quality improvement projects going on in offices that have specifically requested help. We have some students and some medical residents who are working on very focused QI projects and that’s something that I would encourage you to do in any of your metrics in your offices. We did learn a few lessons and this is important. First of all, the biggest one is that we’re very, very busy and again, I mentioned this a couple of times, that competing priorities are huge. This has to be a big why, why are we doing this, why is this important and I think no matter what you do in your quality improvement you need to have a very, very strong driver about why you’re doing this and why you’re making an effort. The other piece is that whatever you do to make improvement it needs to be something that’s very simple that if anything, makes your process in the office smoother. You don’t want to add more work. It needs to be something that’s basically free, that you can scale from office to office to office that you can keep doing. A process where you have people work overtime to call everybody that needs a vaccine that’s behind isn’t going to sustain itself, whereas something that is part of your day-to-day process and makes your day-to-day process easier is something that you can sustain and scale. Another lesson that we learned, which I think is really important, had to do with the feedback that we got from our providers. Which you know as uncomfortable as they were initially with the idea of transparency and everybody knowing how everybody else was doing, they very quickly realized that that provided a really healthy sense of competition and also a really healthy sense of support. Again, remembering why we’re doing this. Physicians have so much knowledge but sometimes we’re missing a key fundamental piece of what really matters and and I think that my partners really appreciated reviewing the science and reviewing the why. They also really appreciated being able to delegate to staff and involve staff in the process and the flip side of it is again the staff really, really enjoyed being part of the solution and part of the messaging instead of just kind of doing the day-to-day labor, they were actually part of protecting life. Finally, in terms of which interventions we used that were rated the highest by my partners and by our staff, everyone really enjoyed the education. So even though education isn’t enough, education is critical. Everyone felt that committing to scheduling subsequent doses before patients left was incredibly effective. And finally, the tools. We really, really enjoyed being able to select the tools that we’re going to work for us within our own offices. And again, all of this is evidence based so we knew that we were choosing from things that had worked for other groups and we were personalizing it to our own office practices. So all of those were rated as the most substantial and effective interventions by my partners. Like to thank you very much for your time today and I hope that our experience in our practice in terms of how we moved the needle in face of all kinds of competing priorities can help you to do the same in your practice with both your HPV vaccination and other vaccines as well as other quality metrics.

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