Medical Home Primer for Physicians

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Medical Home Information for Families

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Creating a Medical Home

Parent Partnership

Practice Assessment

Consumer Awareness

Practice Improvements

Acute Illness Management

Preventive Care Management

Chronic Condition Management

Diagnosis Modules

Transition Information

Community Resources

Medical Home Reimbursement

Quality Improvement

One effective method that primary care practices can use to establish a medical home is the continuous quality improvement (CQI) process. CQI is a concept where the focus is on a team approach to continuous improvement in healthcare. Team members include both practice staff and health care consumers served by the practice. This collaborative approach is the foundation of the process and is essential for successful health care improvement outcomes necessary for creating a medical home.

CQI is a management philosophy which contends that most things can be improved. This philosophy does not subscribe to the theory that “if it isn’t broke, don’t fix it.” It is a set of concepts, principles and methods developed from quality principles proposed by early quality gurus including W. Edwards Deming. These CQI principles, tools, and techniques have been found to work effectively in manufacturing industries and have recently been found to also work effectively in human service industries, including healthcare. At the core of CQI is serial experimentation applied to everyday work to meet the needs of those served and improve the services offered.

Core Concepts of CQI

• Quality is defined as meeting and/or exceeding the expectations of customers.
• Success is achieved through meeting the needs of those being served.
• Most problems are found in processes, not in people. CQI does not seek to blame, but rather to improve processes.
• Unintended variation in processes can lead to unwanted variation in outcomes, and therefore effort is focused on reducing or eliminating unwanted variation.
• It is possible to achieve continual improvement through small, incremental changes using the scientific method.
• Continuous improvement is most effective when it becomes a natural part of the way everyday work is done.

Core Steps in Continuous Improvement

• Form a team that has knowledge of the system needing improvement.
• Define a clear aim.
• Understand the needs of the people who are served by the system.
• Identify and define measures of success.
• Brainstorm potential change strategies for producing improvement.
• Plan, collect, and use information for facilitating effective decision making.
• Apply the scientific method to test and refine changes.
  

A Model for Improvement

• Improvement is based on building knowledge (of what works and does not work) and applying it appropriately.
  
  
• The model offers a “trial and learning” approach that helps reveal the outcomes of change.
  
  
• Three basic questions:
  
  1. What are we trying to accomplish?
  2. How will we know that a change is an improvement?
  3. What changes can we make that may result in an improvement?
  
  
• Test a change on a small scale using PDSA.
  
  P = Plan; D= Do; S = Study; A= Act
  1. Plan the change strategy including who will be involved, what data will be collected, how and when the data will be collected, and when the data will be considered adequate to study.
  2. Plan a small test - one day, 5 records, etc...
  3. Do the intervention.
  4. Study the results.
  5. Act on the knowledge you gain from the data (maintain the plan, modify the plan, add to the plan). Continue with a second PDSA Cycle, and so forth. The process continually builds learning to foster improvement efforts.
     
     

If the “change” was successful, solidify it by:

• Expanding it to the rest of the system.
• Establishing systems to support it.
• Identifying ways in which further improvements can be
  made.

Additional thoughts about improvement efforts:

• Before you try to solve a problem, define it.
• Before you try to control a process, understand it.
• Before trying to control everything, find out what is important, and work on the most important issue or on the process having the biggest impact.
• Recognize that we can learn from failures, so respect “meaningful failures”.

Establishing a Quality Improvement Team
In Illinois, the Division of Specialized Care for Children (DSCC) is working with primary care practices throughout the state to establish medical homes. As part of this work, the practice establishes a Quality Improvement (QI) Team that includes practice staff and health care consumers. Ideally, the QI team includes a lead physician, the staff person(s) who will provide care coordination, staff from the front office involved in scheduling and billing and at least two health care consumers served by the practice (parents and/or teenage children). DSCC provides a facilitator who is knowledgeable of group processes and provides the structure for meetings to be effective.

To initiate the QI team's work, two assessment tools are utilized to obtain baseline data: the Medical Home Index and the Medical Home Family Index. These nationally validated assessment tools were developed by Dr. Carl Cooley and the staff of the Center for Medical Home Improvement (CHMI). These tools enable the practice to assess how well they provide comprehensive family-centered care and identify needed changes for providing a medical home for children with special health needs.

It is highly recommended that a practice distribute at least 30 and obtain no less than 10 completed Medical Home Family Indices for meaningful significance. If you are planning to perform statistical tests, you should consider consulting a biostatistician to determine what sample size would be appropriate to achieve statistical significance for your specific needs. You might aim for a response rate of 35%- 40%, meaning that you should distribute 25% - 50% more surveys than the sample size you are aiming for, but with some patient populations, response rates will be lower.

How do teams assess the results of these tools? The CHMI Medical Home Index (MHI) is divided into 6 domains that define the essential characteristics of a medical home:

• organizational capacity,
• chronic condition management,
• care coordination,
• community outreach,
• data management and
• quality improvement.

The MHI scores reveal the practice's strengths and weaknesses within these areas.

The Medical Home Family Index (MHFI) used by Illinois practices has been adapted so that the questions correlate to the domains of the MHI completed by the practice, thus providing opportunities for the QI teams to compare the practice results with those from families served by the practice. This comparison generally reveals the practice staff and families often agree on the same strengths and weaknesses. However, this comparison also frequently reveals deviations between the 2 groups perceptions about practice strengths and weaknesses - these areas are ideal for the QI team to begin brainstorming about planning improvement changes.

The Illinois Medical Home Project has combined the Medical Home Family Index with the Caregiver Survey to create the Illinois Medical Home Family Feedback Tool. This tool is being used to provide more comprehensive feedback and input from families on their perceptions about the care received from their primary care medical home.

DSCC will score and analyze the MHI and MHFI and develop a written report for practices who are interested in establishing a quality improvement team and developing a medical home. Please use our Contact Us page to obtain more information about medical home and establishing a quality improvement team.

Once the team has reviewed the strengths and weaknesses revealed by the assessment tools, they can begin discussing the processes where improvement would be most beneficial and define specifically the small tests of change they believe will result in improvement. Using the PDSA cycle, described above, the team can define these small tests of change and begin to think and plan for subsequent larger scale changes.

Other Resources

DSCC staff who serve as Quality Improvement team facilitators have developed a Facilitator's Guide to help practices who want to independently begin the quality improvement process.

The Illinois Medical Home Project (IMHP) is administered through the Illinois Chapter of the American Academy of Pediatrics (ICAAP) in collaboration with the Division of Specialized Care for Children (DSCC). The project establishes medical home quality improvement (QI) teams, utilizing parents as partners, with primary care practices. Experienced project staff help support medical home initiatives utilizing the Center for Medical Home Improvement (CMHI) Tool Kit, NICHQ training materials and resources, QI team facilitators, technical assistance, and funding to support participating sites. Facilitators and Technical Assistants utilize knowledge of medical home concepts, family involvement, and QI techniques to support office or clinic-based systems level changes to better serve children and youth with special healthcare needs and their families. The project also uses a public relations strategy and hosts meetings to spread implementation of medical homes across Illinois.

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