2018 TBC Learning Collaborative Session 1, May 09 2018

Welcome!
Implementing Team Based Care (TBC)
Learning Collaborative
National Cooperative Agreement and Community Health Center, Inc.
Session One
May 9, 2018
3:00 - 4:30 EST

TBC Faculty, Collaborative Design, and
Facilitation
AnnMarie R Hess NP, MS
 Consultant
 ahess@maine.rr.com
National Cooperative Agreement
Amanda Schiessl, MPP
 Project Director, NCA
 Schiesa@chc1.com
Nashwa Khalid, MA
 Project Coordinator, NCA
 khalidn@chc1.com
Kerry Bamrick, MBA
 PI, NCA & Program Director,
Postgraduate Residency Training
Programs
 Kerry@chc1.com
Margaret Flinter, APRN, PhD, FAAN
 PI, NCA & Senior Vice President/Clinical
Director
 Margaret@chc1.com
3:35
Mentors, Coaching Faculty
Deborah Ward, RN
 Senior Quality Improvement Manager
 WardD@chc1.com
Kasey Harding, MPH
 Director of the Center for Key Populations
 HardinK@chc1.com
Evaluation Faculty
Kathleen Thies, PhD, RN
 Consultant, Researcher
 ThiesK@chc1.com
Improvement Science Faculty
Patti Feeney, MS
 Manager of Quality Improvement
Education
 HardinK@chc1.com
Mark Splaine, MD, MS
 Director of Education
 SplainM@chc1.com

Get the Most Out of Your Zoom Experience
• Use the Q&A Button to submit questions!
• Please use chat button to tell us the name of your health center and
how many people from your organization have joined the meeting
• Recording and slides are available after the presentation on Moodle
within one week
Q&A Chat

The Community Health Center, Inc. and its Weitzman Institute will provide education,
information, and training to interested health centers in Transforming Teams and
Training the Next Generation
• National Webinars on advancing team based care, implementing post-graduate
residency programs, and health professions students in FQHCs.
• Invited participation in Learning Collaboratives to advance team based care
or implement a post-graduate residency program at your health center.
Access the NCA resources at www.chc1.com/nca
CHC’s NCA on Clinical Workforce Development
The National Training and Technical Assistance Cooperative Agreements (NCAs) provide
free training and technical assistance that is data driven, cutting edge and focused on quality
and operational improvement to support health centers and look-alikes.

WELCOME to
Implementing Team-Based Care Learning Collaborative
 A 10-month participatory learning experience offered by the National
Cooperative Agreement (NCA) to support Clinical Workforce
Development
 Funded by the Health Resources and Services Administration (HRSA)
 Hosted by Community Health Center, Inc. (CHCI) in Middletown, CT.
 Our goal is to help primary care practices in Federally Qualified Health
Centers (FQHCs) implement a more advanced model of team-based care

TBC Learning Collaborative 2016-
2017Name of FQHC City State
Avenal Community Health Center Lemoore CA
Carolina Family Health Centers , Inc. Wilson NC
Community Health Initiatives Brooklyn NY
Daughters of Charity New Orleans LA
Educational Health Center of Wyoming Cheyenne WY
El Rio Tucson AZ
Family Practice and Counseling Network (FPCN) Philadelphia PA
Healthcare for the Homeless Houston TX
Holyoke Health Center Holyoke MA
Johnson City Community Health Center Johnson City TN
Peach Tree Healthcare Marysville CA
Pecos Valley Medical Center Pecos NM
Sumter Family Health Center Sumter SC
Syracuse Community Health Center, Inc. Syracuse NY
The Children’s Clinic Long Beach CA
Tyler Family Circle of Care Tyler TX
Via Care Community Health Center Los Angeles CA

Your Goals
• Access to mentors and coaches, and other FQHCs will help motivate us
to keep our TBC initiative as our top priority for 2018
• Learning from other CHCs will help us gain insight into how to build
and sustain organizational energy around the transformation.
• The structured time , training, and networking will help us advance our
model of care and improve outcomes.
• Access to ideas from other centers that we can adopt will help us
strengthen our current team based care foundation.
*Interviews, 2018

Some of Your Challenges
 Turnover impact team structure, roles, workflow adherence, and
training
 Little or no experience with coaching model
 Lots of recent growth and change
 EHR satisfaction : data, documentation workflows, duplication, quality
 Getting to the ‘next level’ of TBC, lots of staff trepidation
 Resistance to expanding TBC model to all sites
 Competing priorities (too many) and limited resources
 Struggling to provide access to care, meet the demands
 ‘Fitting’ quality improvement work into busy schedules

Name of FQHC Coach
Central Virginia Health Services, Inc. Lisa Dunkum
HealthRIGHT 360 Alan Hernandez Gutierrez
Lancaster Health Center Julie Hoffer
Western Maryland Healthcare (Mountain
Laurel)
Erica Healy, Autumn Rush
New Horizons Healthcare Angela Martin
Northwest Michigan Health Services Gwen Williams
OPTIMUS HEALTHCARE Nelly Angah
San Vicente Family Health Center Cara Johnson
Thunder Bay Community Health Service, Inc. Kayla Berry
Tri-Cities Community Health Whitney Garcia Fraga
Wellspace Health Jeremy Meis
Family Health Center of Worcester Anne Reeder
Thank You Coaches!

Practice Overview
 PCMH+
o 11 Practices Certified
o 3 Practices Level 3
 Total number of patients served
o Range is from 4,759 to 49,521 patients
 Number of practices within organization
o Range is from 2 to 17
 Number of Providers in health system
o Range is from 9 – 130 (MD, DO, PA, NP)
 Electronic Health Records (EHR)
o Include ECW, Athena, NextGen, Greenway
*Uniform Data System (UDS), HRSA

Number of
Teams
Reporting
Level A
Team Practice Assessment
Category
Number Teams
Level A
Behavioral Health Integration 8
Enhancing Access 7
Clinic-Community Connections 6
MA Role 4
Medication Management 4
Communication Management 3
Care Management 4
Layperson (CHW, Navigator) 3
Pharmacist 3
Referral Management 2
RN Role 2
Self Management Support 1
Population Management 1

Opportunity for Sharing Best Practices
UDS Data 2016

https://www.weitzmaninstitute.org/NCA
Advancing TBC Core Concept Resources
2016 TBC Webinars
Webinar #1: Advancing Team Based Care : Building
Your Primary Care Team to Transform Your Practice
Webinar #2: Enhancing the Role of the Medical
Assistant
Webinar #3: The Emerging Role of Nurses in Primary
Care
Webinar #4: Data Driven Dashboards to Support Team
Based Care
Webinar #5: A Team Approach to Prevention and
Chronic Illness Management
Webinar #6: Complex Care Management in Primary
Care
Webinar #7: Achieving Full Integration of Behavioral
Health and Primary Care
Webinar #8: Dissolving the Walls: Clinic Community
Connections
2018 TBC Webinars
Webinar #1: Taking Team Based Care to
the Next Level
Webinar #2: Advancing the Practice of
RNs and Behavioral Health Providers
Webinar #3: Beyond the Walls: Effectively
Utilizing Community Health Workers and
Clinical Home Visitors as Part of the Team
Webinar #4: Caring for Patients with Pain
is a Team Sport
*LEAP Project
Improvingprimarycare.org

Objectives Session #1
1. Introduce participants and opportunities for learning from each other.
2. Review the learning collaborative structure and expectations.
3. Provide an overview of a nationally recognized team based care model,
and resources for learning.
4. Help you ‘get started’ using tools to assess roles and efficiency.
5. Discuss Action Period 1 Assignments, skills and tools you will need.

Session 1 Pre Work
 Post Application Interviews
 Organizing , Communication Planning
 Complete Coach Skills Assessment
 2 Day Coach Bootcamp (April 17-18)
 1 Team Meeting
 Review Effective Meeting Skills
 Review Practice Team Assessment Data
 Complete Team Skills Assessment
 TBC Webinars
 Prepare 2 minute Introduction

Time LS 1 Agenda Lead
3:00 Introductions
Welcome and Background
Amanda Schiessl
Margaret Flinter
3:10 Objectives and Agenda Ann Marie Hess
3:15 2 min Participant Introductions (6) Teams
3:27 Collaborative Structure: Expectations and
Assessment Data | Concepts in TBC: TBC Model
Ann Marie Hess
3:58 Concepts in TBC: Assessment Tools : Role Activity,
Cycle Time
Ann Marie Hess
4:05 Action Period 1 Assignments
QI Utilization: Toolkit Overview, meetings and the
role of the coach
Kasey Harding
4:15 Guest
Your Next Team Meeting
Deb Ward
4: 25 Wrap Up Amanda Schiessl

2 Minute Introductions by Team
Order of Introductions
1 Lancaster Health Center
2 WellSpace Health
3 Optimus Health Care
4 Tri-Cities Community Health
5 Central Virginia Health Services, Inc.
 Name of Your Practice and Size
 Names, FTE, and Positions of
participating Core and Extended
Team Members
 Something your team has done
recently to improve care that you
are most proud of..
 One or two things you want to
learn from other teams.
3:15

Lancaster Health Center
22,000 patients
6 locations in urban Lancaster, PA
65 exam rooms
37 clinicians (26 FTE)

OUR CARE IMPROVEMENT: EMPOWERING OUR MA’S
TO INITIATE ORDERING PREVENTIVE CARE SERVICES
FOR PATIENTS (I.E. MAMMOGRAMS, COLON CANCER
AND CERVICAL CANCER SCREENING)
Extended Team Members
Alex Pineda, LCSW- Behavioral
Health
Georgia Clack- LPN, Care Coordinator
Megan Hess- Care Coordinator for
Gateway insurance
Dorie Rodriguez- Care Coordinator for
Amerihealth Caritas insurance
Lin Hoang, PharmD- Gateway
imbedded pharmacist
TBC Core Team
Mark Sprunger- call center manager
Julie Hoffer- CMA, EHR team
Virginia Rodriguez- LPN
Matthew Weitzel, MD- family doc

• Sacramento, CA and Surrounding Areas
• 14 health centers (more on the way)
• 75,000 patient population
• NextGen EHR
• Fully incorporated Dental (pediatric only)
and behavioral health

• Recent Success:
• Pap smear rates
• Hoping to Learn?
• Scalability
• Team Dynamics

Tri-Cities Community Health
 Multispecialty FQHC located in Southeastern Washington
 9 Locations
 Service Lines
- Family Practice
- Internal Medicine
- Obstetrics and Gynecology
- Pediatrics
- Endocrinology
- Dental
- Behavioral Health
- Optometry
- WIC
- MSS
- Walk-In Primary Care
- Pharmacy
2017 UDS
Medical Patients – 27,858
Dental Patients – 8,974
Behavioral Health – 2,777
Migrant/Seasonal – 8,411

Meet Our Core Team Members
Whitney Garcia (Coach) – Quality & Accreditation Coordinator
Sara Dusky (Co-Coach) – Clinical Pharmacist
Krisinda Wolfe, ARNP – Provider
Otilia Villa – Medical Assistant
Increased Access to Care
 Fall of 2016 our Urgent Care facility was transitioned to a
Walk-In Primary Care to treat both acute and chronic conditions
on a same daily/no appointment needed basis. Efforts to establish wi
th a PCP are then encouraged for follow-up of chronic conditions.
Goals…
1. Strategies to effectively identify Provider strengths and promote
leadership in individual care teams.
1. Effectively communication skills/strategies from front line staff to cl
inical teams, support staff, and clinic leadership.

Tri-Cities Community Health Locations

Central Virginia Health Services, Inc.
• 17 practice sites located throughout Central Virginia
• Current Practice size for the collaborative has:
2 MDs: 1 OB/GYN (PT) 1 Pediatrician ( PT)
1 DO (FT) 2 NP-both (PT)
Nurses , 2 LPNs (FT) MA, 2 (FT)
1 LCSW (FT) 1 Dentist (FT))
2 Dental Assistants (FT) 1 Dental Assistant (PT)
• Electronic Health Record: E Clinical Works (ECW)
Core Team Members Position/Role FTE
Lisa Dunkum, RN Quality Coordinator/Coach FT
Michael Richmond Medical Provider/time keeper FT
Carrie Gladden, LPN Practice Manager/facilitator FT
Shelly Bunn MA/Recorder FT
Mary Linn Wolf FNP PT
Vernita Williams, PSR (FT) Amber Payne, PSR (FT) Seirra Clark, PSR (FT) Lisa Clark-Long, PSR (PT)
Joi Smith, LPN, (FT) Anita Walker, LPN (FT) Jennifer Davis, MA (FT) Kristin Kelly, DA (FT)
Sarah Green, DA (FT) Kim Gimour, DA (FT) Keri Wakefield, DDS (FT)
Erin Kirshowitz, NP (PT) starts June Liz Crotty, NP (PT) leaves June

Central Virginia Health Services, Inc.
What did the team recently do to improve care that we are
most proud of?
Worked on our UDS Measures in the area of Colorectal
Cancer Screenings:
• fit test were made a standing order
• used grant money from HQI to purchase postage to
return FIT cards
• Identified a nurse to call patients and remind them
to return the cards.
• We are currently at 8% and our goal was to
improve the percentage to 36.9% at the end of March, Our
goal was a compliance rate of over 30% by 12/31/18.
Items we want to learn:
1. To improve the efficiency of our quality meetings
2. To increase compliance of UDS measures, specifically
Cervical Cancer Screenings.

3:00 Introductions
Amanda Schiessl
Margaret Flinter
3:27 Collaborative Structure: Expectations and Assessment
Data | Concepts in TBC: TBC Model
Ann Marie Hess
Cycle Time
Ann Marie Hess
QI Utilization: Toolkit Overview, meetings and the
role of the coach
Kasey Harding
4:15 Guest
Deb Ward

Collaborative Structure
And Expectations

 Define Core and Extended
Team (structure, roles)
 Achieve multiple TBC specific
aims, data driven PDSAs
 Standardize (SDSAs) roles and
key processes (Playbook,
Spread Plan- another team)
 Improve team and coach skills
(improvement science, team
work, coaching)
 Move Practice Assessment
Data toward Level A
 Develop a post collaborative
team Improvement Plan
Collaborative Structure and Expectations
Seven 90 min Zoom Learning Sessions
( 3:00-4:30 EST)
Between Session Action Periods (6 weeks)
Meet Weekly as A Team , Conduct Daily Huddles
Complete Assignments
Upload Work to Moodle Folders
Use Online Moodle Learning Network (Share Your Work , Resources)
Between Session
Coaches Meet with Mentors Weekly
Faculty Support
Discussion Board
7
Session 1
May 9
Session 2
June 20
Pre
Work
Session 3
Aug 1
Session 4
Sept 12
Session 5
Oct 24
Session 6
Dec 5
Session 7
Jan 16

Conditions of Success (NCA 1)
 Attendance at collaborative learning sessions and
engagement in weekly coach/mentor calls
 Engagement in work between sessions that
included protected time to meet as a team, trust
and respect.
 Commitment of trained coaches to improving their
skills and helping teams achieve results
 Support of practice leadership for time, resources,
spread and sustainability

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
Learning
Session 2
Learning
Session 3-5
Learning
Session 6-7
Powered by Weitzman
Institute
Core Concepts in Team Based Care Teamwork On-Going Data Collection & Review
Learning
Session 1
May 9

Team Skills Assessment Summary (2018)

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
The Stages of Improvement
Powered by Weitzman
Institute
 1. TEAM AND ROLES DEFINED
Coach Assigned, Identify Core and
Extended Team Members, Define Roles,
Schedule Team Meetings,
TOOLS/SKILLS/PROCESS:
Effective Meeting Tools
Daily Huddles
Communication Plan
 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?
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
Build Consensus
Fishbone Diagram (cause & effect
diagram)
Core Concepts in Team Based Care Teamwork On-Going Data Collection & Review

Team Coach Role and Training (April Bootcamp)
 Help and support teams
working together to use new
skills , achieve their aims,
document their work.
 Help teams complete
assessments and action
period assignments to stay on
track.
 Help teams run effective
weekly team meetings and
facilitate teamwork .

Coaching Skills Self-Assessment

Weekly Coach Mentor Meetings
Tuesday 3:00 - 4:00 pm EST
Kasey Harding (CHCI Mentor)
Wednesday 1:00 - 2:00 pm EST
Deb Ward (CHCI Mentor)
1 Lancaster Health Center 1
Thunder Bay Community Health Service
Inc.
2 WellSpace Health 2 HealthRight 360
3 Optimus Health Care 3 Family Health Center of Worcester
4 Tri-Cities Community Health 4 Centro San Vicente
5 Central Virginia Health Services, Inc. 5 Mt. Laurel Medical Center.
6 Northwest Michigan Health Services, Inc.
7 New Horizons Healthcare
CHCI Mentor Role
 Provide support and resources for developing coaching and improvement
skills
 Assess progress and addressing challenges, help teams stay on track
 Provide individual support as needed

NCA Online Learning Network
Find material for download,
TBC webinars, and team
folders for sharing your work... Improvingprimarycare.org
Discussion Board
Ask questions or make requests
of teams, faculty….

Using Your
Practice Team Assessment Data

Team Practice Assessment: How Do We Shift Levels Toward A?

What is Team Based Care?
Team-based care is a strategic redistribution of work among
members of a core and extended team.
In the model, all members of the team work together for a
common purpose, respect and trust each other, and strive for the
highest quality of patient and family care.
Improvingprimarycare.org

Implementing Team Based Care (gradual approach)
(2016 webinar 1-3, 2018 session 1)
→ Defining your Core and Extended Team Structure
→ Strategically redistributing work among team
members (reduce waste, protocols)
→ Increasing communication among the team,
practice and patients.
→ Creating new responsibilities and provide training
→ Improving efficiencies (wait times, start times)
→ Standardizing processes to reflect new model
(making hundreds available)
→ Using a plan for optimizing the model
→ Meeting Regularly, Huddle Daily

Team Structure and Role Descriptions
www.Improvingprimarycare.org
Patients want to receive their
care from smaller teams
(PODS), know them
personally

CHC|NCA TBC Webinars, www.improvingprimarycare.org

2 Minute Introductions by Team
Order of Introductions
1
Thunder Bay Community Health Service
Inc.
2 HealthRight 360
3 Family Health Center of Worcester
4 Centro San Vicente
5 Mt. Laurel Medical Center.
6 Northwest Michigan Health Services, Inc.
7 New Horizons Healthcare
 Name of Your Practice and
Size
 Names, FTE, and Positions of
participating Core and
 Something your team has
done recently to improve care
that you are most proud of..
 One or two things you want to
learn from other teams.
3:42

Thunder Bay
Community Health
Service Inc.

HealthRIGHT 360
 How many sites? 5 clinics across the Bay Area, multiple residential
and behavioral health facilities across the state.
Staff Role
Leticia Gonzalez Primary Care Provider,
Adam Corona Registered Nurse
Daniela Sanchez Medical
Assistant/Phlebotomist
Alan Hernandez Clinic Operations
Manager
 How many patients served? 6,870 patients, 39,394 visits
 Specialties
 Infectious Disease
 Addiction
 Trans Healthcare

What have we done to improve patient care?
We have had successful PDSAs, our most successful being the decrease in
third next available appointments. We are also a well integrated primary
and psychiatry team that collaborates daily.
What do we hope to achieve?
We hove to improve the quality of life for patients, expand into new much
needed services, and model successful team dynamics.
HealthRIGHT 360

Family Health Center of Worcester, Inc.
• Serves approximately 25,000 patients
• 15 sites – Primary Care, Dental, WIC, and School-Based
Health Centers
• Project Team →
Name Role at FHCW
Anne Reeder (Coach) Quality Improvement
Nurse Coordinator
Karen Hutchinson Clinical Director
Rola Saab Provider, Associate
Director for Quality
Improvement
Beverly Benoit Team Lead Nurse
Yamilex De La Cruz Medical Assistant
Suheily Maldonado Medical Assistant
Karen Puca-Pinho Patient Services Manager
Lydia Santiago Unit Clerk

Accomplishments and Looking
Forward
What is one thing you have done to improve patient care that you are
proud of?
FHCW implemented team huddles for each of its primary care teams. These
huddles meet every morning and allow for the team to connect prior to the
day. They also allow providers and medical assistants to review the pre-visit
planning tool prior to patient visits.
What is one thing you hope to learn from others?
We would like to learn about how others conduct pre-visit planning at their
health centers and incorporate best practices into our care at FHCW.

FTE in Oakland, Md.
Core Team
 Administration: 7
 Providers: 7
 Registered Nurse: 4
 NCC: 3
 BHC: 3
 MA: 8
 PAS: 4
 QI: 1
 IT: 1
 Outreach: 3
 HIM: 3
 Referrals: 3
 Billing: 3
6.398 individual patients
seen past 12 months
 Providers: 2 Shawn Long, MD., Michelle Dixon CRNP
 MA: 2 Kari Bernard, Jeremiah Broadwater
 RN: 1 Erica Healy
 NCC: 1 Stacy Barr
 Pt Access Supervisor: 1 Autumn Rush
 Electronic Prior Authorization

4 Clinics serving 6,519 in 2017
Core Team Members,
all full-time:
 Bree Myers, QI / Data
Coordinator, Coach
 Marisa Herrera, FNP
 Flor Garcia, CMA
 Socorro Martinez, Front
Desk
 Alicia Harmon, CHW
Extended Team
Members:
 Gwen Williams, Senior
Leader Support
 Kim Corliss, Clinical
Services Manager
 Helen Gerig, Care
Coordinator
 Jen James-Witteveen,
LMSW

 Recent Success we’re
Most Proud of:
 Worked together to
increase breast and
cervical cancer
screening rates
 Developed clinical
protocols for order and
result entry
 Developed standing
orders for mammogram
order
 What we Want to Learn
from Other Teams:
 How to work most
effectively as a team
 How to use the team at
the top of their
licenses to address
preventive care needs
in all visits

New Horizons Healthcare
• New Horizons Healthcare-serving 9360 patients annually
• Team Based Collaborative Care Team
(Yellow Pod)
– Ruthie Peevey, NP Kelsey Kingery, PAR
– Sani Widner, NP
– Vicky Robinson, LPN Coaches-Angie Martin
– Melissa Taylor, MA Missy Stevens
We recently achieved PCMH level 3 with a “perfect score”
We hope to learn best practices and share innovative ideas for
team based care with other centers

“Transformation to team based care requires that primary
care physicians and other health professionals envision new
roles for themselves and that practices incorporate new
paradigms of how best to care for patients”.
Both of these challenges are more difficult than anyone had imagined.

Polling Question
On a scale of 1-5
How challenging or difficult has it been for your practice to
implement new roles and new ways of caring for your patients?
1 2 3 54
Extremely Difficult
(evidence we are not
doing much of this)
Not Difficult At All
(evidence we are
doing this well)

Action Period One
Assessment Tools
4:08
Cycle Time (Efficiency)
Role Activity Analysis
Key Points : Team Based Care Model
→ Strategically redistribute work among team members (reduce waste, duplication, variation)
→ Increase communication among the team, practice and patients (meetings, huddles,
messaging)
→ Improve efficiencies (role duplication, variation, interruptions, wait times)

Assignment:
Assess Cycle Time
to Improve Efficiency
Electronic or Manual

15 Patients (1-2 weeks)
Use Clipboard with Clock
Select One Appointment Type
Random Selection Patients
AM and PM
Target 1.5 X Appt Time
15 min Appt = 23 min cycle time
SampleData.Hess.2009
Worksheet.clinicalmicrosystem.org
Note: scheduled appoint time
Subtract Early Arrival Time

Hess.CPM.2010
Problem:
Assessment data shows
long cycle time.
Root causes identified
using Fishbone Diagram.
Process map current
state pre visit planning,
rooming workflow.
Informs Next Session :
aims and small tests of
change.
High Leverage Change Ideas: Possible Quick Wins

Role Assessment and Processes : Webinars 1-8

Role Activity Assessment (customizable)

Process Source of Complaint, Impact on Quality and Goals , Role Variation and Duplication,
Healthcare for the Homeless NCA 2016

Role Tracking Worksheet
Consider
Tracking
Interruptions
Role Activity Analysis
Position:
Tic Marks
(each time
activity done,
may add AM,
PM)
Total Tic
Marks
Estimated
Time per
Activity in
minutes
Total Time
Access and Communication Processes Activity
1. Schedules patients with a personal clinician for
continuity of care ||||| ||||| ||||| 15 4 min 60 min
2. Coordinates visits with multiple clinicians and/or
diagnostic tests and procedures
3. Triages how soon a patient needs to be seen
including a process for after-hours care
4. Monitors access to appointment, backlog and wait
time using telephone and email requests
5. Monitors and triages secure patient portal
messages
6. Provides advice on clinical issues via telephone or
portal messaging
7. Identifies and arranges for language services
8. Collects patient demographic and insurance
information, including preferred method of
communication
9. Helps patients activate their Personal Health
Record by signing up during office visit
10. Identifies and refers patients who might benefit from
care management support, other practice resources,
community services
Population Health Management Activity
1. Uses population registries and clinical quality
reports to monitor a panel of patient’s health and
risk status and close care gaps.
2. Communicates with many patients at once via bulk
outreach letters and portal messaging (e.g.
reminders for preventive care visits ,testing,
screening gaps)
3. Provides outreach services to patients overdue for
visit to follow up management of chronic

76
33%
67%
Non-Physician Tasks Physician Tasks
Non-Physician Tasks
-immunizations
-obtaining consults
-obtaining MR
-setting up room
-filling out clerical fms
-finding interpreter
-bringing pt to room
-data entry
-finding information

SampleData.Hess.2009
Worksheet.clinicalmicrosystem.org
IHI.org Poster
25%
75%
RN Activity
[planned care
registry, triage
level 2, nurse
visits, self
management
support]
Sampling of a Typical Day
RN Role
Ticks and Tally

3:00 Introductions
Amanda Schiessl
Margaret Flinter
3:27 Collaborative Structure: Expectations and
Assessment Data | Concepts in TBC: TBC Model
Ann Marie Hess
Cycle Time
Ann Marie Hess
QI Utilization: Toolkit Overview, meetings and the role
of the coach
Kasey Harding
4:15 Guest
Deb Ward

Action Period 1 Assignments (May 9th to June 20th)
1. Meet weekly (50 min) as a Core Team
 Practice effective meeting skills and use tools with coaching support
Next Team Meeting
 Establish Core and Extended Team Structure and Roles
 Use Practice Team Assessment Data to Identify Priorities for Improvement
 Draft Your Global Aim Statement
2. Continue or Test Daily Huddle
3. Complete Role Activity Analysis
4. Complete cycle time assessment, or use system reports
5. Use assessment and other practice data to state a problem
6. Complete a fishbone diagram – identify drivers of a problem
7. Map a process
8. Submit readiness survey (ORIC) by June 11th .

Tools for Running
Effective
Meetings

Tool for
Assignment:
Writing
Global Aim
Statement

Assignment:
Improve
Daily Huddles
Carolina Family Health Center, NCA 2016

Assignment: Complete a Fishbone Diagram and Process Map to
Understand Problem and Opportunities

Resources can be
found in the following
places on the main
Moodle page.

This was a memorable and valuable experience to be a part of.
I really enjoyed getting to know what other health organizations are
doing and how we can relate and also learn from those experiences.
The mentor calls were very helpful and empowering.
This is a learning experience that provides growth both for your
organization and yourself. Great experience!
I hope the 2018 Teams take advantage of all of these amazing
opportunities!
Good Luck!
TEAM COACH
Karla Rodriguez, RN, BSN, PHN
Nurse Educator, The Children’s Clinic
Long Beach, California
NCA 1 Team Coach Reflection

Guest
Dr. Rajiv Modak
El Rio Health, Arizona

5 MINUTE TEAM DEBRIEF-
NEXT MEETING
1. Meet weekly (50 min) as a Core Team
 Practice effective meeting skills and use tools
with coaching support
Next Team Meeting
 Establish Core and Extended Team Structure
and Roles
 Use Practice Team Assessment Data to
Identify Priorities for Improvement
 Draft Your Global Aim Statement
2. Continue or Test Daily Huddle
3. Complete Role Activity Analysis
4. Complete cycle time assessment, or use system
reports
5. Use assessment and other practice data to state a
problem
6. Complete a fishbone diagram – identify drivers of
a problem
7. Map a process
8. Submit readiness survey (ORIC) by June 11th .

NCA Contact Information
Amanda Schiessl
Project Director
(860) 266-8665
(860) 347-6971 ext.
3650
Schiesa@chc1.com
Nashwa Khalid
Project Coordinator
(860) 852-0806
(860) 347-6971 ext.
3699
Khalidn@chc1.com
Next Team Based Care Learning Collaborative Session
#2 is scheduled for Wednesday, June 20th at 3:00pm
EST

2018 TBC Learning Collaborative Session 1, May 09 2018

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2018 TBC Learning Collaborative Session 1, May 09 2018

Editor's Notes