Building a quality improvement (QI) infrastructure within team-based care is an organizational strategy that will establish a culture of continuous improvement across departments and improve quality in all domains of performance. Many positions in primary care now require QI training as part of employees' professional development. Our expert faculty discuss tools you can use to build and implement a QI infrastructure within your team-based setting to improve patient care. Panelists: • Deb Ward, RN, Senior Quality Improvement Manager, Community Health Center, Inc. • Kathleen Thies, PhD, RN, Consultant, Researcher, Weitzman Institute

1. Quality Improvement Strategies in a
Team-Based Care Environment
March 24th, 2022
1:00-2:00pm Eastern / 10:00-11:00am Pacific
Kathleen M. Thies, PhD, RN and Deborah Ward, RN

2. Continuing Education Credits
In support of improving patient care,
Community Health Center, Inc. / Weitzman
Institute is jointly accredited by the
Accreditation Council for Continuing Medical
Education (ACCME), the Accreditation Council
for Pharmacy Education (ACPE), and the
American Nurses Credentialing Center
(ANCC), to provide continuing education for
the healthcare team.
A comprehensive certificate will be sent after
the end of the series, Summer 2022.
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3. Disclosure
• With respect to the following presentation, there has been no relevant (direct or indirect) financial relationship
between the party listed above (or spouse/partner) and any for-profit company in the past 12 months which
would be considered a conflict of interest.
• The views expressed in this presentation are those of the presenters and may not reflect official policy of
Community Health Center, Inc. and its Weitzman Institute.
• We are obligated to disclose any products which are off-label, unlabeled, experimental, and/or under
investigation (not FDA approved) and any limitations on the information hat we present, such as data that are
preliminary or that represent ongoing research, interim analyses, and/or unsupported opinion.
• This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of
Health and Human Services (HHS) as part of an award totaling $137,500 with 0% financed with non-
governmental sources. The contents are those of the author(s) and do not necessarily represent the official
views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit
HRSA.gov.
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4. At the Weitzman Institute, we value a
culture of equity, inclusiveness, diversity,
and mutually respectful dialogue. We
want to ensure that all feel welcome. If
there is anything said in our program
that makes you feel uncomfortable,
please let us know via email at
nca@chc1.com
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5. National Training and Technical Assistance Partnership
Clinical Workforce Development
Provides free training and technical assistance to health centers across the
nation through national webinars, learning collaboratives, activity
sessions, trainings, research, publications, etc.
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6. Objectives
• Define Quality Improvement (QI)
• Outline a common model for QI
• Recognize the importance of data and how to use it
• Describe Clinical Microsystems approach to QI
• Understand how to implement Clinical Microsystems approach
at your health center
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7. What is Quality Improvement?
“Quality improvement (QI) consists of systematic and continuous actions
that lead to measurable improvement in health care services and the
health status of targeted patient groups.”1 - HRSA
To do this, teams need actionable data.
“Every system is perfectly designed to get the results it gets.”2
–Paul Batalden, MD
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1. US Department of Health and Human Services, Health Resources and Services Administration. Quality improvement. 2011.
https://www.hrsa.gov/sites/default/files/quality/toolbox/508pdfs/qualityimprovement.pdf. Accessed March 21, 2022.
2. Nelson, E. C., Batalden, P. B., & Godfrey, M. M. (Eds.). (2011). Quality by design: a clinical microsystems approach. John Wiley & Sons.

8. What are we improving? Measuring?
Crossing the Quality Chasm (2001)
• Efficiency
• Safety
• Effectiveness
• Equity
• Patient-centeredness
• Timeliness
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Source: Institute of Medicine, Crossing the Quality Chasm: A New Health System for the Twenty-first Century (Washington: National Academy Press, 2001).
https://www.nap.edu/catalog/10027/crossing-the-quality-chasm-a-new-health-system-for-the

9. Common Model Used in Health Care
Institute for
Healthcare
Improvement
Common mistake:
people start here.
These should be
measurable.
Source: http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx
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10. Common Models that Require Special Training
Six Sigma/DMAIC Lean/Six Sigma
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1. https://www.qualitymag.com/articles/94429-back-to-basics-six-sigma
2. https://www.greycampus.com/blog/quality-management/a-brief-introduction-to-lean-and-six-sigma-and-lean-six-sigma

11. Team &
Roles Defined
Assessment
And
Baseline Data
Global Aim
Problem
Statement
Change
ideas/
solution
storming
Specific Aims
and
measures
PDSA
SDSA
Spread
Measure
and
Monitor
CHC’s Stages of Improvement
On-Going Data Collection & Review
Not a linear process: iterative
These stages overlap with and are an adaptation of several models, e.g., the IHI
model (PDSA) and DMAIC (Define/Measure/Analyze/Improve).
Source: Thies, K., Schiessl, A., Khalid, N., Hess, A. M., Harding, K., & Ward, D. (2020). Evaluation of a learning collaborative to advance team-based care in
Federally Qualified Health Centers. BMJ Open Quality, 9(3), e000794.
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12. Origins
• The Dartmouth Institute (Nelson, et al., 2011)
• Institute for Excellence in Health and Social Systems at the University of New
Hampshire (Godfrey, et al., 2022)
https://clinicalmicrosystem.org/
• Inspiration: Toyota assembly line
• Theory based
– Ecological systems theory in human development1
– Experiential learning theory2
1. Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and design. Harvard University Press.
2. Kolb, D. A. (2015). Experiential learning: Experience as the source of learning and development. 2e Saddle River, NJ: Pearson.
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13. What the Models Have in Common
All focus on process improvement to
improve efficiency and effectiveness and
eliminate waste
• Measure current state
• Set and measure performance targets
• Trial small tests of change
• Sustain change
Use similar tools:
• Process maps, swim lanes
• Fishbone diagrams
• Aim/Target Statements
• Variations on PDSA cycles
• Playbooks
• DATA
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14. Patient/family
Clinical microsystem:
frontline teams
Mesosystem:
pop health, BI, IT
Macrosystem:
organization
Exosystem:
community/society
Systems Approach in Health Care
Transactional relationships across systems
Source: Nelson, E. C., Batalden, P. B., & Godfrey, M. M. (Eds.) (2011). Quality by design: a clinical microsystems approach. John Wiley & Sons.
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15. Clinical Microsystems approach to QI
• A clinical microsystem in health care is “a small group of people who
work together on a regular basis to provide care to discrete
subpopulations of patients. It has clinical and business aims, linked
processes, and a shared information environment, and it produces
performance outcomes.”
• Built on the premise that the people who do the work know how the
work can be improved.
• QI is not a department.
Source: Nelson, E. C., Batalden, P. B., & Godfrey, M. M. (Eds.) (2011). Quality by design: a clinical microsystems approach. John Wiley & Sons.
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16. Microsystems and Team-Based Care
• Clinical Microsystems improvement team is “a small group of people who work
together on a regular basis…,” also the principle of team-based care
• Consistent with the foundations and functions of team-based primary care:
systems-oriented, data-driven, team-based.
• Built on a team culture of “Share the Care,” not “my patients” but “our patients”
 culture of “share the outcomes”  “share the process of improving the care”
• Begins with the team doing an assessment of their own practice (data), not PDSA
cycles or proposing solutions.
Source: Ghorob, A., & Bodenheimer, T. (2012). Sharing the care to improve access to primary care. The New England Journal of Medicine, 366(21), 1955-
1957. doi:10.1056/NEJMp1202775
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17. Quality Improvement is about Teams
• It’s not a department.
• It’s a philosophy, a culture.
• It’s what happens “on the field.”
• It’s about team performance.
• Sports teams know their performance stats.
• And they work on improving their
performance every day to improve their stats.
• What about your teams? Share the
improvement?
Read Moneyball by Michael Lewis, 2004
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18. Quality Improvement is about Data
Data-driven care is a building block of primary care and team-based care
• Where does the data come from?
– Electronic health records, insurance claims, HR…
• Who enters the data?
– STAFF: Does your staff understand they are doing data entry every day? The
biggest problem with data integrity is faulty data entry.
• Where does the data go?
– Data warehouse, dashboards, reports for CMS, UDS…
• Who reviews the data?
– QI department? Administration? Does your staff know their data?
Source: Bodenheimer, T., Ghorob, A., Willard-Grace, R., & Grumbach, K. (2014). The 10 building blocks of high-performing primary care. The Annals of
Family Medicine, 12(2), 166-171.
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19. Data is used to:
Track the health of an individual patient
Track the health status of populations of patients, disparities
Track cycle time, no show rates
Predict trends in utilization of care
Track costs associated with care
Reimburse care
Benefit from value-based contracts
Continuously improve care to justify further investments in care
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20. Infrastructure for Data: Business Intelligence
• BI systems combine data gathering, data storage, and knowledge
management with analytical tools to present actionable information to
planners and decision makers.
• BI provides actionable data structured so that it is meaningful and can
be acted on by staff: dashboards, reports, graphics, etc.
• Without the right data in the right hands at the right time in the right
format, you cannot improve performance or measure performance.
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21. Data: Population Health and BI
• Teams caring for a panel of patients who don’t have data about their
panels in the aggregate cannot do population health management*, or
improve or measure their efficiency and effectiveness related to
population health measures (e.g., UDS).
• Population health, BI and QI work with frontline teams and across
systems
• Population health data is the foundation of value-based contracts.
• $$$
*function of primary care
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22. Example of actionable population health data:
% pediatric patients with persistent asthma prescribed inhaled corticosteroids.
What action is needed?
Brown line= “Provider Brown” Blue line = “Blue clinic” Green line = All peds clinics
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23. CHCI Quality Improvement
How QI works at CHC
–Performance Improvement
Committee
–Teams and Coaching
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24. We use Clinical Microsystems approach to QI:
• Data-driven, team-based, systems oriented
• Begins with assessment of current practice, not PDSA cycles
• Provides a data-based systematic approach to changing practice—the
improvement ramp
• Improvement ramp provides a shared mental model of improvement for the
team
• Uses many of the same tools as Lean/Six Sigma
• Utilizes coaches to guide frontline teams through the improvement process
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25. CHC’s Performance
Improvement Structure
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26. Category Goal topic Specific Goal Source 2020 Rate
Current rate
(11/21)
Current Goal
Recommended
Goal
Chronic disease care
Diabetes control
Increase the number of patients with an A1c
(HbA1c) less than 9.0 percent
UDS 57.97% 65.39% 70% 70%
A1C testing
Reduce the number of patients with diabetes
who have not had an A1c completed in the last
12 mo.
CHC 22.00% 13.54% 5% 5%
HTN control
Increase the number of patients with
hypertension whose BP is controlled (less than
140/90)
UDS 46.82% 51.47% 70% 60%
BP documentation
Reduce the number of patients with
hypertension who have NOT had a BP
documented in the last 12 months
CHC 26.30% 17.00% 10%
Home BP cuff use
Increase the number of patients with HTN who
have a home BP cuff
CHC
0.7% (last 12
mo)
11%
New goal:
input from
Team
1. Category
2. Goal topic
3. Define Specific goal
4. Source
5. 2020 Rate
6. Current rate
7. Current Goal (2021)
8. Recommended Goal
• Chronic Disease
• Screening
• Behavioral Health
• Preventative Care
• Population Health
• Dental
• Medical and Dental
• Prenatal
Performance Improvement Goals
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27. Next Steps
1. Existing Teams:
i. Is the team on track to achieve goal(s) for the year?
ii. Any modifications needed?
2. New Teams:
i. What type of team (micro/meso)?
ii. Team composition?
iii. Coach?
3. Process in Place:
i. Is the existing process sufficient and likely to achieve the goal(s)?
ii. Any modification(s) needed for the process?
iii. Catchball back to a Microsystem for testing/refinement needed?
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28. Potential for
Spread?
Individual Site
Priorities
Sustain
metrics, competencies, training, policy/ procedures
CHCI Performance Improvement Goals & Objectives
No
Internal Quality Monitoring
Quarterly Quality Reviews, Peer Review, Patient
Satisfaction, Annual Performance Reviews
External Requirements
Joint Commission, UDS, HRSA,PCMH+, Meaningful Use, State
Licensing
Co mmu n it y Hea l t h Cen t er , In c .
Qu a l it y Impr o v emen t Mo d el
Mesosystems Microsystems
Catchball*
Microsystems
Project
Team Project
Workout
Session
Kaizen
Project Summary Review/ Report Out to PI
New Process Development
Agency-Wide Implmentation
Process Playbook Created
Yes
*catchball refers to a new process designed by a Mesosystem that is referred to a local microsystem team for further testing a nd refining
Project Summary Review/ Report Out to PI
New Process Development
Goals categorized into
three main groups:
1) New Teams
2) Existing Teams
3) Existing Process
How we use it.
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29. New Teams
New QI team Topic Detail
Diabetes control
Increase the number of patients with an A1c (HbA1c)
less than 9.0 percent
A1C testing
Reduce the number of patients with diabetes who
have not had an A1c completed in the last 12 mo.
HTN control
Increase the number of patients with hypertension
whose BP is controlled (less than 140/90)
BP documentation
Reduce the number of patients with hypertension
who have NOT had a BP documented in the last 12
months
Breast Cancer Screening
Increase the % of women with appropriate
mamographic breast cancer screening
Cervical Cancer Screening
Increase the number of patients who have appropriate
cervical cancer screening
3 CRC
Colorectal Cancer
Screening
Increase the number of patients who have appropraite
colorectal cancer screening
4 Antipsychotics
Metabolic monitoring for
antipsychotics
Increase the number of children and adolescents (ages
1-17) on Antipsychotics who have metabolic
monitoring
5 Pedi Well-care/recall Well care 12-21
Increase the number of children and adolescents ages
12-21 with at least one annual well care visit
Develop and implementat a process to accurately
capture patient Race and Ethnicity
Update the quarterly chronic disease dashboard to
report outcomes for African American and
Hispanic/Latinx populations separately
Reduce the rate of uncontrolled hypertension in
African American patients
6 Equity
Population health
1
Diabetes Control
HTN control
Cancer screening
2
Discussion at PI/Steering
Committee meeting
• Change idea solution storming
• Is it a micro/meso system?
• Does this need a coach?
• Where to test?
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30. Coach Training within Health Centers
• Identification of the new coach
• Communication with leaders
• Commitment from the coach in training and supervisor
• Training (six to seven didactic sessions)
• Mentor program
• Monthly Coach meeting
• Reports to Performance Improvement/Steering committee
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31. Why CHCI uses it
• Data-driven, team oriented
• QI happens where the work happens
• QI is done by the people who do the work
• Builds on unique context of individual staff in specific clinical units in a
larger organization
• Elevates skill level of staff, ownership of improvement and practice,
team-ness
• Uses trained coaches to guide staff
• Structured, systematic “mental model” for how to improve
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32. 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
 6. SOLUTION STORMING for CHANGE
IDEA
What could we try?
Realistic ideas, Manager|Leader involvement.
TOOLS/SKILLS/PROCESS:
Idea Tree
Parking Lot
Force Field Analysis
Impact Effort
Multi-Voting
 7. PDSA
Aim, test, who, when, where.
PLAN Tasks: How will we do it? What, Who,
When, Where. Predictions, Measures
DO: Lets try it out. Results
STUDY: How is it working out? ACT: Lets try it
again with modifications?
TOOLS/SKILLS/PROCESS:
PDSA Template
Keep test SMALL
Only one PDSA at a time
Measures
On-Going Data Collection & Review
 1. TEAM AND ROLES DEFINED
Coach Assigned, Identify Core and Extended
Team Members, Define Roles, Schedule Team
Meetings, Communication Plan
TOOLS/SKILLS/PROCESS:
Effective Meeting Tools
Forming/Storming/Norming/
Performing
 2. ASSESSMENT AND
BASELINE DATA
What is our current state? Describe population
of interest, Identify data sources, Drill down to
specific areas of focus. Related to other
projects?
TOOLS/SKILLS/PROCESS:
Tick & Tally & other data collection
Process Mapping
Role Assessment
Team Practice Assessment
 3. GLOBAL AIM
What is our overall goal for advancing TBC
Model? Theme, Name process, location,
Start/End of Process, Benefits/Imperatives
TOOLS/SKILLS/PROCESS:
Build Consensus
Fishbone Diagram (cause & effect diagram)
 4. PROBLEM STATEMENT/THEME
Problem Statement, Importance, Goals/
Objectives, Deliverables, KPIs
TOOLS/SKILLS/PROCESS:
QI Charters as agenda items
Brainstorming/ Brain writing
Multi-Voting
Impact/ Effort Grid
Fishbone Diagram
Five Whys
Process Map
Build consensus
 5. SPECIFIC AIMs and MEASURES
What do we want to accomplish in days and weeks
? What will change, by how much & when , How
will we know that we accomplished it?
TOOLS/SKILLS/PROCESS:
Specific Aim Tool
Build Consensus
Fishbone Diagram (cause & effect)
Tick & Tally & other data collection
 8. SDSA
Standardize the test that was successful. Will it
work the same in every day routine? Document.
TOOLS/SKILLS/PROCESS:
Involve all team members
Communication Plan
Playbook – Influence Spread
 9. SPREAD, MEASURE & MONITOR
Implement spread strategy and track how it is
working.
TOOLS/SKILLS/PROCESS:
Communication Skills
Spread Strategy
Big Picture View
Connecting the dots
QI Process
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3
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8
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33. Continuous Monitoring
for Success
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Site A Site B Site C Site D Site E Site F Site G Site H Site I Site J Site K Site L Site M Site N

36. Questions?
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37. Contact Information
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For information on future webinars, activity
sessions, and learning collaboratives:
please reach out to nca@chc1.com or visit
https://www.chc1.com/nca