Transforming Clinical Practice Initiative - Practice Transformation Experts - TCPI National Faculty Alumni

The TCPI National Faculty Alumni are a dedicated group of healthcare quality improvement experts who shared their own expertise and experience across multiple areas to support the TCPI Community. The material below provides a brief summary of each Faculty member’s experience in transformation, organized by the five components of Quality Improvement:

1. Improvement Capability
2. Patient Safety
3. Person & Family-Centered Care
4. Triple Aim for Populations
5. Quality, Cost & Value

National Faculty Alumni Performance Summary

Quality Improvement Components:

1) Improvement Capability

“I am passionate about helping independent pediatricians excel in the new healthcare age that puts quality over quantity and emphasizes patient engagement and satisfaction.” Ashraf Affan, MD

I am the President and Founder of Angel Kids Pediatrics, the largest private pediatric practice in Northeast Florida. I have been a pediatrician for more than 25 years and established the practice by myself in 2004 as a single-provider operation with one front office staff. Today, Angel Kids Pediatrics has grown to one of the fastest growing businesses on the First Coast with more than 110 employees including 25 providers, serving more than 20,000 families in the greater Jacksonville area. Through a care model built on patient engagement, and by applying innovative quality measures, we were able to reduce cost and improve quality by 29% per member per month for different payers.

Today, Angel Kids staff come from various diverse backgrounds and experiences, and the organization’s commitment to diversity is clear through its aggressive outreach and recruiting efforts with more than 51% who identify as minority. The organization prides itself in being a trusted resource for the community, this is attained by its commitment to its mission of striving to provide excellent care in a family and community-based environment.

I believe that pediatrics is a unique field as it begins at birth when healthcare for babies begins and extends well into adolescence. It is a delicate balance of knowledge, patience and the ability to relate to children and their families. Optimizing care and prevention at an early age ensures the ability to improve healthcare outcomes later in life.

“Aims create systems and systems generate results.” Zandra Glenn, PharmD

I am a pharmacist consultant with over 20 years of experience working with the safety-net environment, pharmacy management and large-scale quality improvement government programs. I served a co-lead for the HRSA Patient Safety and Clinical Pharmacy Services Collaborative (PSPC), member of the National Content Developer (NCD) for the CMS Partnership for Patients campaign to reduce hospital-acquired conditions by 40 percent and preventable 30-day readmissions by 20 percent., and the Medication Therapy Management (MTM) Program Improvements Contract to help improve the delivery of MTM services in Medicare Part D and assure that beneficiaries experience consistent MTM services across plan sponsors. I currently serve as the lead for Action Learning Activities for Transforming Clinical Practice Initiative (TCPI) and participate in the management and execution of quality improvement programming that support the achievement of TCPI aims and serve an improvement coach for several practice transformation networks (PTNs). I also serve as a member of the management team of the Alliance for Integrated Medication Management (AIMM) which is a collaborative path to the triple aim through rapid cycle development of service delivery pathways, using comprehensive medication and population management as a core discipline.

In my role as a quality improvement consultant, I am a strong advocate of the phrase “aims create systems and systems generate results.” As organizations establish bold goals that will transform the quality of care for patients, we will create systems, unimagined, that will achieve breakthrough results.

“You have to know where you are going, otherwise your effort is wasted.” (Alice in Through the Looking Glass by Lewis Carroll) Alan Kimura, MD

I am President of Colorado Retina Associates (CRA) the largest single-specialty ophthalmology group (vitreoretinal diseases) in the Rocky Mountain West. Our 125 staff and 12 physicians in private practice centered in Denver, work out of six offices across Denver Metro; a seventh office serves the mountain ski communities. Our fellowship expertise in inherited retinal diseases, uveitis and ocular tumors attracts patients from the entire region.

We are amidst a Lean culture and process transformation, diffusing a staff-led, continuously improving clinical flow of greater efficiency. More respectful of patient time and need, a patient-centric paradigm shift is integral to two office buildouts, incorporating the input and approval of the low-vision community in the architectural design. Early adopters of EHR and participation in the American Academy of Ophthalmology’s IRIS Registry (the world’s largest QCDR with 50 million unique patients and 200 million visits annually) helped CRA achieve a MIPS score of 100/100. CRA leverages both financial and clinical data to inform business intelligence. We invest back into staff training, external site visits to peer practices, and selectively upgrade to new imaging technologies that will be of value to patients. CRA was the first practice in Colorado to complete TCPI training, and was named as an exemplary practice by TCPI for its commitment towards delivering value by: preferential use of cost-effective off-label biologics to treat macular degeneration and diabetic retinopathy; 2/3 major surgeries performed at cost-effective ambulatory surgery centers rather than hospital setting; net promoter score tracking with continuing patient surveys; and surgical rounds to diffuse surgical experience across the multi-generational surgeon workforce.

“Leading transformation is about listening to and engaging my team to help produce action.” Misty Parris, RCEP

I am the Vice President of Operations, Northwest Network which is part of the PeaceHealth Medical Group located in Whatcom, Skagit and San Juan Counties in Washington state. PeaceHealth Medical group is a large hospital system and encompasses both Primary Care and multi specialties. The primary care patient population for the Bellingham and Sedro-Woolley area is approximately 60,000 patients and includes both rural and suburban areas. Our service area also included migrant and refinery workers.

Over the past five years, we have developed several processes for improvement which include standard rooming process, pre-visit preparation, team based care, care management and transparency on our performance metrics. I believe what has ultimately moved us forward on our journey for improved quality is the engagement of leadership as well as the team. In addition, displaying our work and providing transparent feedback through our performance board has continued to drive improvement. Our biggest change occurred when we started to communicate both our current areas of strength and weakness. We also did not dictate what needed to be done, but we allowed the people doing the work to help drive processes for improvement. We continue to raise the bar on our metrics by setting targets to reach our final goals.

“I have found that coming together with a common goal is the best way to facilitate transformation.” Greg Wolverton

I am the Chief Information Officer at ARcare and lead a Knowledge Management System staff that delivers services to over 70 sites in Arkansas, Kentucky and Mississippi. ARcare is a federally qualified health center headquartered in Augusta, Arkansas which provides healthcare to approximately 150,000 patients. The system consists of ambulatory clinics in Arkansas, Kentucky, and Mississippi that include long term care, pharmacy Behavioral Health and HIV/Aids services. The patient population ranges from small, rural farming towns to large urban area.

At ARcare, highly effective teams have worked to redesigning practice workflows, including the development of clinical electronic health record algorithms that resulted in a 5% improvement in overall hypertension control and a significant increase in the identification of patients who previously did not have a hypertension diagnosis.

2) Patient Safety

“By using technology tools to capture population level health data, we can plan for and maximize each office visit so that patient has a better experience and better health outcomes. Teams are key to ensuring that all of the work gets done so that no one experiences burnout or misses key metrics.” Sarah Chouinard, MD

I am the Chief Medical Officer of Community Care of West Virginia (CCWV), a federally qualified health center with multiple locations throughout nine counties in Central West WV. CCWV consists of primary care offices and school-based health centers with approximately 37,000 patients. The patient population consists of a very rural Appalachian group of isolated communities with very few other healthcare options in our service areas.

We have been using data to drive improvement over the last five years. In 2016 we were better than the West Virginia state average in 9 out of 13 clinical measures. The most powerful function we have in our office is our technology tools that allow us to track both performance measures and outcome measures. We provide routine feedback to all members of the care team about performance with close follow up to ensure that goals are being met and improvements are being made via PDSA. We use routine webinars, face-to-face meetings, and close control over data to ensure progress across our large geographic spread. Our culture is truly continuous quality improvement. Adopt the mantra,” ‘That’s the way we've always done it' is now forbidden language." Everyone must be open to change. Change means progress.

“Start with a gut check: what transformation project invigorates your desire to come to work and grow from there.” Meggan Grant-Nierman, DO

I am a partner and Family Medicine Physician at the privately owned First Street Family Health in Salida, CO which has approximately 8,000 patients. We serve a rural community, and tend to patients from up to two hours away in the surrounding rural communities of the south central Rockies. I have worked hard for two years to develop a plan for transitioning into team based care for our office. We have also developed a Patient and Family Advisory Council that has provided robust patient feedback for enhancing that patient experience.

Our practice has found that transformation works when physicians and leadership who are forward-thinking and unafraid of change are aligned with a common goal. We celebrate successes with everyone and point out to them how they are the ones who made the practice succeed. As we develop a culture of improvement, we empower staff at all levels to come up with problems to tackle and to engage in the process of improvement. The transformation journey starts with physicians and nurse leadership and needs to identify priorities, those individual intrinsic motivators and emotional drivers that bring us to work every day.

“If you aren't measuring it, you aren't improving it!” Brenda Kennedy, DHA, MBA, BSN, RN, FAIHQ

For over 23 years, I have served as the Quality/Compliance Officer of ARcare, a federally qualified health center headquartered in Augusta, Arkansas that provides healthcare to approximately 130,000 patients. ARcare consists of 39 clinics in Arkansas, 5 clinical sites in Kentucky, and 1 site in Mississippi. In addition to primary health care services, we also provide pharmacy, Ryan White, behavioral health, and wellness programs. The clinic locations range from small, rural farming towns to large urban areas.

Over the last several years, we have been successful in establishing a quality program that provides useful and actionable data, information, and tools for our leadership and clinical staff. Our highly effective teams have dramatically improved rates of screening and intervention for depression, substance abuse, and tobacco use for our populations and have maintained annual screening and intervention levels above goal for the last several years. Developing effective and sustained quality improvement in clinical practices is a journey that requires communication, commitment, and consistency.

“Transformation is really just starting to do things the way you have always wanted them done! Only do not do them alone. The first thing is to form a solid leadership team with a shared vision of where you all want to wind up. This is the basis for all of the team-based work that follows. With that team on board, you can accomplish anything!” Kirsten Meisinger, MD

I am the Medical Staff President for the Cambridge Health Alliance (CHA), a safety net ACO, located north of Boston, Massachusetts. I also work as a Family Medicine physician at Union Square, a full-spectrum Family Medicine primary care site with approximately 8000 patients. The patient population includes a large mix of Brazilian, Spanish-speaking, Nepali, Indian, Haitian-Creole and other immigrant groups; many of these patients are uninsured. Our highly effective teams have been able to achieve and maintain quality goals for cancer screenings, diabetes and depression treatment for over five years. We have also quickly surpassed all of our immunization and new mental health screening goals in the past year.

We have found that high functioning teams are the cornerstone of the exceptional quality attained and maintained by Union Square. Multi-lingual, highly trained and effective staff maximize every opportunity to achieve quality care through both in-reach and outreach. We know how to deliver high quality care to the most vulnerable population in the country! Talk to us.

“Being a breast cancer survivor and having been on the other side of the fence, I know how important it is to provide patient focused care emphasizing high quality and compassion.” Sabiha Raoof, MD, FCCP

I am the Chairperson of Radiology at Jamaica and Flushing Hospitals in Queens, New York. These hospitals are both private community hospitals that provide safety net coverage to a diverse population that speaks over 100 languages. Both radiology departments combined perform approximately 240,000 exams per year.

Over the past two years I have leveraged the American College of Radiology Imaging 3.0 change construct to ensure our departments are prepared for value-based care. I have also initiated a hospital-wide patient outreach program. Teams are assigned to each floor and each team member rounds on patients once a week to find out about their hospital experience. Any issues raised are solved in real time.

I have found that communication and data transparency are key qualities in my practice. These qualities foster accountability and ownership of performance standards and help us achieve excellence. In order to transform, we must be focused, define priorities, and use data and evidence based guidelines to drive our transformation. My motto is to empower my team and give responsibility with accountability. I have rediscovered the joy in caring for others and found satisfaction in my work.

“There is no health without mental health.” Anna Ratzliff, MD, PhD

I am an Associate Professor Department of Psychiatry & Behavioral Sciences at the University of Washington in Seattle, Washington where I have developed expertise in suicide prevention training, mental health workforce development, adult learning best practices, and mentorship. One role within TCPI includes leading a national collaborative care training program for the American Psychiatric Association SAN. I am also the Director of Integrated Care Training Program for residents and fellows and the Associate Director for the AIMS (Advancing Integrated Care Solutions) Center.

I lead training and quality improvement efforts for our two Collaborative Care Programs: the Mental Health Improvement Program (MHIP) and the Behavioral Health Improvement Program (BHIP). MHIP is a state-wide program serving safety-net populations in community health centers in the state of Washington where more than 35,000 patients have received integrated mental health services since January 2008. BHIP uses Collaborative Care to bring mental health treatment into 15 UW Neighborhood Clinics – a system of primary care clinics located throughout greater Puget Sound Area in Washington State. Pay for performance quality measures were introduced to MHIP to drive clinical processes critical to achieving better patient outcomes. We significantly reduced the time to improve depression rates. I encourage all practices looking to transform, to define a clear vision of what successful behavioral health integration would look like in their organization and make that clear goal the focus of the transformation effort.

3) Person & Family-Centered Care

“I lead this team from within. There is no ranking here. Our system is created and run by its members.” Jane Anderson, DNP, APN, C-FNP, C-ANP

I am the Director of the University of Minnesota Health Nurse Practitioners Clinic, the first all -Nurse Practitioner managed and led clinic from M-Health and the University of Minnesota School of Nursing. I am also an Assistant Clinical Professor for the DNP Doctoral Program at the University of Minnesota, School of Nursing.

UMN Health Nurse Practitioners Clinic, which consists of consists of 4 clinics and a primary care site within an Independent Senior Living Community, is a full-spectrum, newborns to end-of-life, primary care clinic. Our patients live in the urban community that surrounds the clinic in Minneapolis. One example of a unique population that we serve is our partnership with an organization to serve a population of patients who are transitioning from homelessness as well as other patients in transitional supportive housing. We partner to educate and manage their significant health needs, comorbidities and lack of trust of the health care system.

Through appropriate access to care, in the past year we have steadily built a panel of patients who are well-educated and managing their chronic conditions through self-care to avoid unnecessary clinic visits. We have seen a significant reduction in emergency department calls and visits, and hospital stays by the patients in both supportive housing environments, through providing access, education of the patients and care coordinators (when appropriate). Our power comes from our team of NPs, on-site pharmacists, certified medical assistants and our patient representative (and soon to be dental practitioners.) We absolutely adhere to shared governance in our clinic for all members of the team.

“People with special needs, and their caregivers, have enough challenges in life; navigating a disparate, complicated health care system shouldn’t be one of them.” Susan Brown, MPH, CPHIMS

Employed in health care for over 25 years, I am currently a Director at Telligen in Des Moines, Iowa overseeing our contract work for the Quality Payment Program. Prior to Telligen I was a Project Manager for Kaiser Permanente. On a personal note, I have two adult children with a serious genetic syndrome. This led me to co-found a local non-profit group “Let’s Soar Together” and to become a Care Minister at my local church for special needs families. I also serve on two local health care Boards. From years of navigating the health care system, I am passionate about sharing positive suggestions that benefit both the patient/caregiver experience and the goals of the providers involved.

“Patient engagement is a vital component of healthcare and I am a firm believer in the philosophy don't make decisions for us without us.” Desiree Collins-Bradley

I have been the Family Advisor for Texas Children’s Hospital in Houston, Texas for the past seven years. My daughter was born with a rare genetic syndrome, Jarcho-Levin Syndrome. Her medical journey has inspired me to become an advocate not only for her, but in the medical community as well. I believe in the pillars of family centered care and it is my passion to spread the importance and awareness of them. I have become involved in several committees at the hospital, including the Newborn Center Family Advisory Committee, of which I am the Co-chair. I am also a Family Advisor for the Vermont Oxford Network, which focuses on NICU improvement projects globally, and the Project Coordinator for Project DOCC Houston, a nonprofit organization focusing on the importance of partnerships between physicians and families of those taking care of a chronically ill or disabled child.

“Our healthcare system is very complex and it is easy to forget that patients are the real customers in the care transaction. My passion is to make sure everyone remembers that.” Randy Fenninger, JD

I have been the Chief Executive Officer of the National Blood Clot Alliance (NBCA) located in Vienna, Virginia since 2014. My interest in patient and family engagement began when my daughter was hospitalized for surgery and was physically lost by hospital staff between her room and the OR. It was then that I realized that patients need an advocate at all times. My own medical experience with bilateral pulmonary embolisms, Factor V Leiden and becoming a lifetime anticoagulant patient further cemented my desire to make sure that patients are recognized as the true "customer" of the health care system.

Critical elements such as timely, accurate diagnosis in the emergency room and proper hospital discharge planning and education were missing elements in my hospitalization. As an NBCA volunteer, I learned that my own medical experience was repeated in far too many instances. Patient and family engagement at all steps in the medical process clearly is key to making sure that each person suffering a blood clot receives appropriate care at all times.

“A strong community is built on proficient advocacy, and change is predominant when voices ignite.” Precious McCowan, BS, MS

At the age of nine I was diagnosed with juvenile diabetes. Living with this condition progressed my kidney failure. By the age of 27 I was placed on hemo-dialysis. In 2010 I received both a kidney and pancreas transplant. Unfortunately, I had to return to dialysis and insulin shortly after transplantation due to organ rejection. Throughout this challenging yet rewarding journey, I have served as a Facility Patient Representative (FPR) for my dialysis clinic, where I heartily work to advance patient health engagement and renal education for a better experience of care while on dialysis.

Acquiring the passion to assist those affected by End Stage Renal Disease (ESRD) assisted my affiliation with the ESRD Medical Review Board (MRB) and the ESRD Patient Advisory Committee (PAC) of Texas. As a patient advocates with the ESRD PAC, I partner with ESRD caregivers and medical professionals to effectively meet the needs of those living with kidney disease. I am also involved with the National Patient and Family Engagement Learning and Action Network (NPFE-LAN), which supports renal patients nationally in developing activities that focus on kidney health care and patient safety. In 2017, I joined the Kidney Community Emergency Response (KCER) team, which provides a forum for ESRD patients to collaborate to establish emergency readiness planning for dialysis units. I am grateful for this opportunity to advocate and support those challenged with ESRD because this is a condition altering the lives of millions around the country.

“The future of pharmacy practice has arrived and pharmacists are more ready than ever to collaborate and innovate to drive healthcare forward.” Christine Rash-Foanio, PharmD

I am a Clinical Pharmacist and Clinical Assistant Professor at the University of Illinois-Chicago, an academic medical center located in Chicago, Illinois. I am also the Pharmacist Care Coordinator of Ambulatory Internal Medicine & Managed Care. The patient population consists of the urban and underserved patients in the heart of Chicago. The clinical pharmacist patient care panel includes a total of 876 patients with diabetes, 124 patients with asthma, and 152 patients with cardiovascular disease. These patients are seen either in person, by telephone, or both. I provide clinical pharmacy services within a primary care clinic. Within the clinic, I oversee the clinical quality of patients insured by our medical center's largest private contract, Blue Cross Blue Shield HMO of Illinois.

High-risk patients are identified by analyzing real-time data on our patient's medical conditions, ED visits/admissions, and medication usage and the pharmacist care coordinator is responsible for reaching out to those patients, coordinating follow-up as appropriate (PharmD visits, PCP follow-up visits, specialist visits). Through clinical pharmacy services, our patients have access to on-site medication management, medication reconciliation, preventive services (screening and immunization), and education/behavioral counseling. These services are tied to Quality Improvement incentive funds provided by our private payer contracts.

Over the past 3 years, Clinical Pharmacist-led quality improvement activities in primary care have helped bring our primary care sites from low to high-performing status (4 stars out of an overall 5) with our largest private contract at our institution. Clinical pharmacy services have aided in improved access to and quality of care for diabetes, asthma, cardiovascular disease prevention and management, and medication management. I encourage all to let go of the fear of the unknown! Everyone on this journey is on an untraveled path and we can succeed together.

4) Triple Aim for Populations

“Create a culture of quality improvement by measuring quality to identify areas of opportunity, engaging the whole care team, starting small and spreading what works.” Beth Averbeck, MD

I am the Senior Medical Director for Primary Care and also a practicing physician for Geriatrics at HealthPartners in Minneapolis, Minnesota. HealthPartners Medical Group serves approximately 500,000 patients at 29 clinics in urban and suburban areas. We have a diverse population with the largest ethnic communities that we serve being Somali, Hmong, and Spanish.

Over the past ten years, we have been one of the highest performing medical groups across multiple health measures as publicly reported by Minnesota Community Measurement. Our care model process, which uses a team approach to standardize clinical practice, enabled HealthPartners Medical Group to become one of the first large multi-specialty group practices in the nation to be recognized as a Patient-Centered Medical Home by the National Committee for Quality Assurance. In addition, we have received the American Medical Group Association’s Acclaim Award twice and were an honoree once.

We use data to continuously identify areas of opportunity to make system changes at the care team level that improve the quality of care for patients and the practice of medicine for our care teams. My advice to practices starting transformation is to start socializing the ideas and involving and engaging those that the changes may affect. Involve care teams and patients in the design.

“Transforming healthcare isn’t easy, but few things that are worth fighting for are.” Marijka A. Grey, MD, FACP

I am a practicing Internist and a Regional Medical Director for WellSpan Health, a multispecialty not-for-profit medical group located in South Central Pennsylvania and northern Maryland. There are over 1200 physicians and Advance Practice Clinicians in the medical group in over 145 different clinical sites and 6 hospitals. The patient population includes a range from Amish/Mennonite communities to suburban to mid-size urban areas. WellSpan works as an integrated organization, purposefully looking to see how we can improve quality across all spheres of our organization with National Center for Quality Assurance Patient Centered Medical Home and Specialty Practice designations, an integrated, system wide EHR and a dedicated Quality and Improvement team whose goal is to improve our processes on a daily basis to result in the highest level of care that we can provide, at each and every patient encounter.

My work can be summarized in 4 words: Imagination, Integrity, Integration & Innovation.

Our position is one of vigilant oversight and active curiosity to question the current state.” Tess Kryspin Lombard, MD

I am a practicing internist and Chief Medical Officer for StayWell Health Center, a federally qualified health center in Waterbury CT. Our patient population is primarily insured through Medicaid and 25% of our patients are served in a language other than English. We provide integrated care that includes Behavioral Health, Dental Services and Substance Abuse treatment. I have had the honor of working at other community health centers in Connecticut and have experience in private practice and Hospitalist Medicine.

During this career journey I have appreciated being able to impact patients on an individual level, as well as through population management. We have been able to accomplish this through Quality Improvement in Action and the utilization of accurate data shared in a transparent manner. We are excited to participate in telemedicine and Chronic Care Management to continue to improve the health and wellbeing of our patients.

“We are working to have patients engaged in making things happen more efficiently, effectively, and valuable to them.” Lisa Lewis, MD

I am a native of Colorado and have practiced obstetrics and gynecology in the western suburbs of Denver since 1992. I practiced in a large group, then started a solo gynecology practice in Lakewood, Colorado after receiving my Masters in Public Health from Columbia University’s Mailman School of Public Health in 2009.

My small practice is an incubator of new ideas and a better way to practice medicine for me and my staff, much of that thanks to TCPI. We are focused on patient experience and engagement. From there, we made a number of small but impactful changes to our practice that contributed significantly to system wide savings in our community. Our small practice, like a few others participating in TCPI, are proving that you do not have to be big to provide value. I hope that I can use my faculty role to spread what I have learned, and am learning, to all those who in are interested in the principles of TCPI. I am part of a collegial and engaged medical community and am working on creating meaningful coordinated care with my peers so that our patients have seamless care.

“Be bold. Fail forward. You can do this!” Mary Reeves, MD

I am a Family Medicine physician. I spent my 22 clinical practice years at First Street Family Health (FSFH), a 4 doctor independent practice serving a rural population in the central Colorado mountains. Salida, Colorado is a small town (pop. 5300) that has a critical access hospital; the only hospital for 1 hour in any direction and is 2-3 hours from tertiary care. FSFH started its transformation journey as part of the Comprehensive Primary Care Initiative (CPCI) in 2011.

By coordinating patient care, we were able to reduce emergency room visits by 22% in 1.5 years despite overall growth in our practice. Implementing Team Based care strategies opened access, improved office efficiency and morale and increased revenue. Transformation has required a major culture change for our practice. We are an old practice and fears about what transformation would mean for our long-serving employees was a major challenge. We were intentional about not wanting to lose employees during the transformation and used financial incentives for education and time to change workflows. All take pride now in our progress. I retired from clinical practice in 2015, but the journey continues as FSFH is a CPC+ practice that is navigating track 2 payments under the QPP.

I recommend that practices start their transformation journeys with empanelment and risk assessment, using that data to identify, strengths, priorities and improvement opportunities. I also recommend starting a Patient and Family Advisory Council early on – it will bring a supportive patient voice to your transformation efforts. TCPI brings technical support to practices for this transition that benefits patients, clinicians and staff and positions the practice to benefit from new payment models. It is my honor to serve as faculty and share my experience and excitement with practice transformation.

5) Quality, Cost & Value

“Either I am the greatest doctor in the world, or I am a good doctor surrounded by great processes.” Montgomery Elmer, MD

I have been the Chairperson of Thedacare Primary Care Compensation committee for the past 22 years. Thedacare is a non-profit, multi-specialty delivery system located in Appleton, Wisconsin consisting of seven hospitals and 34 primary care clinics that serve with approximately 240,000 patients and includes both rural and suburban areas.

For the last five years Thedacare has led the Wisconsin Collaborative for Healthcare Quality (WCHQ) metrics for disease management/preventive care metrics. We have also been the value leader for the Pioneer ACO project. We have had exceptional success in utilizing lean process improvement in healthcare. We redesigned our workflows, goals, and mission to truly focus on patient needs and desires. Lean process improvement is a "tool box" that operates within the organizational culture you create. In order to transform, we had to first understand and accept that healthcare in the United States is going through a profound change. The shift from volume to value is upon us.

“Failure is fertile ground for team-based primary care transformation.” Karen Funk, MD, MPP

I am the Vice-President of Clinical Services at Clinica Family Health, a federally qualified health center, in Lafayette, Colorado. We have approximately 47,000 patients with 97% of our patient population living at or below 200% of the poverty line. Clinica Family Health was the first community health center in the state of Colorado to achieve NCQA Level 3 patient-centered medical home status in 2010.

Our robust, integrated team-based environment sustains quality outcomes for our vulnerable patient population over time. For the 13 quality outcomes that we track for which there are Healthy People 2020 goals, Clinica Family Health has met or surpassed goal for 8 of them. We have maintained a 2% readmission rate for our population through our inpatient service with partner hospital Avista and our home-visit based transitions of care program.

Our organization values continuous improvement of actionable business intelligence tools that continue to push the boundaries of what is possible with population management for all roles on the care team. We have been able to clearly define roles on the care team so that everyone can see and value what they have to offer in the care of the patient; this helped to transform how we worked as a team to deliver quality health outcomes. In order to transform you must be brave and trust that the group is wiser than the individual.

“Working together is better for everyone; think like a system not a silo.” Carol Greenlee, MD

I am a clinical endocrinologist with over 30 years of practice experience ranging from urban to rural; group practice to hospital-employed to solo self- employed. I have worked across the country from Indianapolis, Indiana to Allentown, Pennsylvania to Atlanta, Georgia and, for the past several years, in Grand Junction on the western slope of Colorado. In May 2016, I closed my small solo private practice, Western Slope Endocrinology, but continue to work ardently on practice transformation and new models of care delivery, especially as regards specialty care and integration of care across the medical neighborhood. I am currently chair of the ACP Counsel of Subspecialty Societies (CSS), also chairing their collaborative work group on coordination of care, and serving on the ACP Board of Regents.

Western Slope Endocrinology became one of the first specialty practices to receive recognition as an NCQA tier 3 Patient Centered Specialty Practice (PCSP) in 2014. We exceeded benchmarks in all of our diabetes measures by use of registry and patient-centered team care. However the biggest achievement was putting high value care coordination into practice and helping to spread it locally, improving the referral process and communication, building better working relationships and connections between clinicians and practices and providing care that is more patient centered. I believe that during the transformation process of specialty practices it is important to remember the mindset of serving the whole community from which the referrals come, the referring clinicians as well as the patients and families and finding ways to more adequately and appropriately meet those needs.

Dr. David Hanekom is Chief Executive Officer of Arizona Care Network, a physician-led accountable care organization founded on the principles of the Quadruple Aim: improve population health with high quality care, enhance the patient experience, reduce the cost of care, and improve provider satisfaction. An internist by training, Hanekom is an experienced physician executive with demonstrated success in medical management, managed care, payment transformation and population health management. He brings innovation and a collaborative approach to the design, implementation and operational oversight of value-based programs.

Additional Information

For additional information, please contact transformation@cms.hhs.gov.

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