Process changes. Process changes, we're kind of taking out Loma Linda as the middleman, which I think would be a lot simpler, and having internalizing it to ASLD. So I want to introduce Elizabeth Dursey, ASLD Vice President for Publications and Practice Resources. But before we get to that, you know, we have a good agenda, learning agenda today. And then we'll have some opportunities for people to provide feedback or suggestions for changes or how we do things moving forward. Tosia, any comments? Yeah, I think we covered it all. Great to see everyone again. The PACT agenda, we'll hear from Elizabeth in a minute, but just to review the objectives, we'll look at a site is controlled data today. And we try to move, I think, to go forward in terms of thinking about what ideas can we implement in our practices for improving the site ease. That's what we're focusing on. So you'll hear more about it from Sumit's group, because they've started on a quality improvement project that I think we can learn lots of lessons from. And then our quality coach would go over that with her as well. And I think the main goal for today is to seek as much important feedback from all of us to identify aspects that we can work on between now and the next time we meet. Okay, so Liz. Hi, everyone. Thank you both and Dr. Conwell for introducing me. I'm excited to be here. As they both mentioned, ASLD as the Vice President of Publications and Practice Resources. A mere three months ago, we're getting closer to four months, but we'll say three months for now, mere three months ago. And thankful to this team. They've been very patiently teaching me everything that there is to know about the CQC registry, and I'm excited to be here. As Dr. Volk mentioned, the ASLD is committed to developing a health learning resource for focused on improving care and outcomes for patients with cirrhosis. And that we're the association is sort of steering us towards transitioning from our pilot and test and learn phase to expanded development. So that's where I'm coming into play to sort of take sort of the larger picture at this point and sort of figure out what direction we're going to go and start working with the team on potentially implementing that. So I'm very excited to be here. Since I've only been here for three months, I am mostly, I will call myself an observer at this point in time, still learning quite a bit about the program and everything that you all are doing. So for the next two hours, I'm very much looking forward to learning as much as possible from all of you. And I appreciate the generous 10 minutes you gave me to introduce myself, but I know we packed agenda today. So I'm going to move on quickly and turn it back to Dr. Volk. Right. So before we get into kind of the learning part, I want to take a deep dive into one of our measures, which is the CITES control. And so I'd like to share my screen. Okay. So can you all see my screen? Yes. All right. So, and hopefully all of you have logged into the site and played around with the data a little bit. You know, you have the several pages here. One is the main page, the admin dashboard, and then you have your patient list and then your registry reports. And there's the scorecard, which is the summary for all the different measures. And there's an engagement report, volume report, detailed reports, comparison report, and valid score, SIRCOM, which is comorbidities. I'm going to go into the detailed reports. Okay. And so you can select a measure or CITES control. And so here is the CITES control. And so we have all CITES, all genders, all ages, and the response date. So key thing for everyone to know is that we are still making tweaks to how this is presented. You know, we've all been gathering data and the data keeps coming in, but we still don't have it kind of perfected. And you might've noticed a big change recently in this run chart, which is it used to bounce around a little bit, and that's because it was not being presented correctly. It was being presented as the most recent data. Whereas, you know, that's just random noise, right? We want to see if there's actually a trend. And so this is a 12 month rolling average. Again, we're still making a few minor tweaks, but the point is, this is your opportunity as a group to let us know what you think should be changed, what would be more useful to be able to see. One example is that we have, let's say, let's look at Loma Linda. So we've requested the ability to dive down and say, okay, let's say we're at 82% right now. Who are the people that don't have good assays control, right? I'd like to know who those patients are. So that's still in progress, but we'll have that functionality soon. So here, I want to open it up to the group and see what questions you have about this particular measure. If there's anything we can change, any input, feedback. If you do have, as you're working with the data, if you do have specific suggestions or requests, please feel free to email Sheila. Fasiha, any comments and input on this? I think you covered it. I just want to make sure everyone has looked at this for their sites. Because that's where I think these are the data that we're looking for. As Michael mentioned, still a work in progress, but there are going to be tweaks. The data are there for quite a few metrics. So we just want to make sure that you know A to A how to get to it. If you have difficulty, let us know. And we start reviewing this information. Our goal is to be able to drill down to individual patient level. I think that's coming very quickly, but still this information, I find it to be very useful. So if you have not had a chance to look at it, take a look at information for your sites and also comparison with other sites too. I don't know about the rest of you, but I found this particular data point very interesting. These are all patients with known cirrhosis followed in by our liver clinics. And only 85% are abstinent. So that's kind of scary. Michael, could you pull to a few different sites also? Yeah, so we could try to do a comparison report. So for some reason, yeah, so this is one example of something that we're still working on tweaking with our metrics. But for some reason, this is still is not showing all the sites. But so this is how it is drinking. This is Jack Lake. Maybe could Andrew comment about that? Because I know that's an issue. We can't see our own data. Actually, yeah, I can actually. I got an email this morning letting me know that you guys don't have access to it, just a provisioning issue. And by the end of this year, we'll be able to just a provisioning issue. And by the end of today, you'll be able to see yours in. Okay, thanks, Andrew. Yeah, so this is exactly a perfect example of why it's so important for all the sites to go through, spend some time, block out some time in your schedule, spend some time playing around with this and review it with your team and then send us questions because, you know, that's how we identify flaws that we need to fix. Let's see. Volume report was another one that I think is still needs work. So I think some of the sites are probably measuring it's being measured as all the health system covert. Yeah. And some of the sites is so. So we need to make sure that we so kind of covert. So that's probably makes more sense to people, right? Yeah. So the ones that are health system covert, there's only a few sites that have the health system interface set up. So that's another plea to all of you to get the health system interface set up. Please work with Sheila and our metrics to get that in your IT folks. Because I think that's to me, that's huge because we look at the difference in size between the health system covert and our kind of covert. That means that there's a lot of patients in our health system that are not seeing us in clinic. And we know the type, right? They're the frequent flyers to the ER patients that show up for primary care, but don't come to liver clinic. So those are probably the ones that need the most quality improvement. Yeah. I think this information in itself, it's useful and I think consistent with the overall goal. We're getting this data, sites are coming on. I think we have four that are able to now send EMR data. I think the fifth one should be able to send the next few weeks. So making progress. I can just make sure we keep the momentum going. I'm glad you're showing that. That was another thing, Michael, that I was hoping you can review the medical school information. It's only for the sites that are sending the EMR data. It's not coming from the PROs, but you can see variability variation in this as well. And then we can look at the CIRCOM data. So the point of the CIRCOM is that the long view of this is that we want to eventually do value-based care. And we want to figure out which are the patients that their care, the cost of their care and healthcare utilization is driven primarily by their disease versus other comorbidities. I'll tell you when I talk to managed care groups, their impression is all these patients have multiple comorbidities. So this is just one of many, but actually that's not true. Look at this. I mean, majority of them, actually, I'm going to take a picture of this because I have a managed care group I was just talking to this morning about this. So really most of them, it's just their liver disease. All right. Any other questions, comments about the data? Dr. Volk, could you just help me understand the CIRCOM score a little bit better? Yeah. So CIRCOM zero means that they have no comorbidities. They just have cirrhosis. And then one plus zero is one comorbidity, one plus one. So there's different levels of comorbidities. Yeah. And this score is little, you have to look at the actual diagram to figure out what these scores mean, but Michael is right. The higher the number, the greater the comorbidity. These are also conditions that have the most impact on outcomes in patients with cirrhosis. So they're not just any comorbidity. These are the comorbidities that influence patient outcomes the most. It's just a combination of that. Any other comments or questions? If not, we'll go on to the learning agenda and quality improvement agenda. Sheila, do you want to bring the agenda back up? Okay, great. So while we are still working on tweaking the data, I think the most progress we'll be able to make as a group are in the grassroots efforts that each of you are doing. And so we'd like to invite Dr. Oswani and his team to report on their root cause analysis and their improvement on ideas. Yeah, I think Dr. Oswani is still not here, but I'm happy to present what we have done the previous weeks since our last call. So yes, my name is Philipp Schulze and I'm a research assistant here with Dr. Oswani since July. So yes. Next slide, please. Yes, exactly. So what we actually did since our last call, you provided us with the fishbone sheet. And the idea was that we, or we handed it out through medical and non-medical staff in our outpatient clinic. And we just asked for their insights in terms of ascites. So what is, what are the related problems which they're thinking what could be fixed or are causing this biweekly, weekly ascites, paracentesis in these patients. So afterwards, these patients, these coworkers then had three weeks to pull out this sheet and in addition then we had two meetings with the hepatologists and one with the with the clinical staff as well just to discuss what's the current status and how we can actually fix some of the problems and one of the findings was that one of the the major driver is eventually the lack of patient education at least for our side so and then we went ahead and we created and previewed and implemented new patient educational material which I will present shortly so next slide please so this is actually all the the comments of medical non-medical stuff in terms of patient system medical management process issues some might overlap and in red you will find the actual problem and green is stated what is right now implemented to yes to aim one of these issues in blue are potential solutions for an issue and as I said one of our main findings was that we for our side we don't have had much in terms of patient education in place so we thought this would be the easiest approach for now to address and to provide educational material to patients and their caregivers but of course there is still a lot of pending like we don't have anything like a scheduled phone and follow-up phone call which we should probably implement sooner or later or we don't discuss patients who weekly or bi-weekly show up for paracentesis and just review them and come up with a care plan as group so yes and also one of the other ideas is that there might it might be helpful in the future if we implement we use epic here is a medical record system that we might implement like an allot for patients who coming in just for okay did we check the patients for the rate for the labs for their medications did we check whether we can adjust the dose and stuff like this and yes that's basically are there any questions in terms of this so far okay next slide please okay what we have actually done so far and I will also show this shortly we created posters and about cirrhosis, ascites, hepatic encephalopathy and hidden costs which are associated with an increased sodium intake and we are also showing now videos to our patients and explaining the complications about cirrhosis, ascites, paracentesis, hepatic encephalopathy and some of their essential nutrition facts and these videos will be or they are broadcasted in our outpatient clinic in our waiting room in our procedure room where the patient will be tapped right now and also in our hospital in the patient room directly we have set up a channel so that the patient can switch to the channel and they will see this educational video and in addition we also have created handouts they were already vetted partially by Baylor here but we also found that it might be easier that we create additional ones just to simplify the most essential facts about nutrition and I will show them shortly and the feedback from the patients so far has been overall good I mean there are a lot of information out for the patient and sometimes hard to to bring them down to what is really essential for the patients and what they should focus on and in terms of ascites it's at least what they should remember is a two gram sodium intake maximum per day so yes we can go to the next slide please so this is one of the posters and before I go ahead all these pictures are actually downloaded from cirrhosiscare.ca this is created the website by the University of Alberta and thanks to Dr. Tandem and her team because we also set up a call referral just told her what we have done so far and we whether we allowed actually to use a material and they agreed that we could so on the left side you will see a poster explaining cirrhosis so what liver does and what are actually the driver of cirrhosis what the patient can expect from their future treatment from the diagnostic standpoint as well what are potential complications and how these complications will be treated and we also on the right side you will see the ascites poster just briefly explaining what is ascites what are the sign of ascites and we then have a section what's the patient just just the take-home message so what can I do just to lower of course the sodium and also taking a meds and showing up for appointments and what how is it actually treated from our side and from the health and health care provider side and also what is the paracentesis and how it's conducted and we also implemented some QR codes which will direct the patients firstly to the YouTube video which we also uploaded on YouTube so it's the same cirrhosis educational video which will be broadcasted in the clinic for the patients and it will also guide the patients either the other QR code to the cirrhosis care website where they can find additional information and where they can also sign in or sign up for an account and then just complete a survey pre and post-educational survey so and this information will be collected the patient agrees to it this will be collected in RedCap on the side of University of Alberta so that we can actually see whether this whether the implementation or the materials the educational material actually has any impact on the knowledge and on the confidence of the patient so next slide please yes these are the other two process the left one is a hepatic encephalopathy this is not in place yet and this needs to be reviewed with the hepatologist but this is more or less and it's explaining hepatic encephalopathy what are the signs and how is it treated and what the patient should keep in mind in the future at the very bottom and it also has the QR codes like the other process and on the right side you will see actually what it was an idea from one of our hepatologists Dr. Magupia on our side so he said you know maybe the initiatives just to explain patients in a different way when they eat fast food or unhealthy food that it not only cost two or five bucks they're actually hidden costs associated with these yes with this fast food I mean lost work days driving to clinic and co-payments for seeing a doctor and so on and these these posters or handouts they will be printed soon I mean the handout we will give it to the patient as handout right now and we will also create posters which will hang then in our clinic in the exam room in every exam room and probably in the lobby as well yes next slide please so this is just some screenshots of the content of the video which will or which is broadcasted in the clinic so once again it's addressing cirrhosis in general the causes the complications and what a side is is actually and how is it treated with paracentesis and if you scroll down a little bit it also covers and essential parts of hepatic encephalopathy and and I think four or five um nutrition facts which is essential and the future treatment and this is actually yes next slide please is good this is actually the nutritional sodium handout on the left side is the one which we created here just um summarizing what what too much sodium content actually why it's why it's unhealthy and simply just a view visualizations for patients what is healthy food what they can actually eat of course um unsalted unsalted food or um healthy and fresh um vegetables or fruits and what they should basically avoid and also when you scroll down a little bit you will also see that patients often actually unfortunately don't know what is actually the sodium content at least what they told us and that we just briefly explain um on the right lower side okay there's where you can find the actual sodium can content and a few patients also mentioned that they actually have problems to writing it down what they actually eat and I mean this is still an issue but um we right now we also provide some refresh sheet where they can write down the actual um ingredient what they eat and also their view tracking apps just to keep track of the sodium what she eat what they eat per day next slide please so this is just um a short summary of many pilots which we done which we have done we started to play the videos the educational video in the rating room we showed it to or showed it to the patients while getting tapped and and this videos in in total 15 minutes long it's a it's a compilation of the cirrhosiscare.ca videos which we merge into one single video and if you scroll down a little bit you will also just um like the handout which we um for the handouts you also included the QR codes and directed the medical staff in the clinic just to help patients how the QR code actually works on the phone if they have any problems and also we're setting up right now the video channel for our inpatient clinic and so the patient can watch it there while yes in the clinic or in the hospital so and the last slide please so actually what is next um as I mentioned briefly the collaboration with the University of Alberta it's probably that we um as I said the patients have the opportunity to sign up on this website and for a survey pre and post-educational survey so that we can actually analyze whether our educational intervention actually are successful or there's any change and of course we also have a large population of Spanish-speaking people so we have we are glad we have a certified translator on our team who's right now and they're translating all this material and into Spanish so that we also have it available in Spanish so and if you scroll down a little bit this is these are the short-term goals and the long-term goals is ideally that we upload all this material on our Baylor Scott and White website and we probably also want video interviews directly with the health care providers MDs or nurse practitioners who just explain briefly what is fibrosis how is it treated so that the patients know okay I know this person I trust it and I trust him and it's probably just a different approach and what we also thought as a potential solution if we implement a situs or a paracentesis clinical checklist so once the patient comes in that we check whether we included all the necessary lab parameter did we check for the diuretics are there any side effects did we eventually also refer to a alcohol abuse program did we refer eventually to a dietician so these are definitely ideas for the future and they are still in progress and the same applies to to the EPIC lab which will hopefully be done sooner or later so that um in all that or a message pops up once the patient comes in with weekly or bi-weekly asides or paracentesis so that we can actually have it automated all these future diagnostic procedures yes that's it from from our side and any questions oh that's uh that's awesome you've done a lot of work um I have a couple questions one is um the video um is that something we could show at other sites does it have um any Baylor branding on it no nothing yeah um I can I can share the link or the link is um included in there and the posters you can just scan it and then you will um direct it directly to YouTube and then it's where you can watch it this that would be a great um example of how we all yeah come on resources um Sheila what did we decide about what's the site that we're going to use to post all these resources box so I can I can put this on box that's right okay that's right yeah could we um have a link to the box um from our CQC website that way people lose the the box address in our email we can just easily get to it that way from the Arbometrics site or from ASLD one probably the ASLD one okay I can yeah yeah so the website has different videos and what Philip had done he had spliced a few together and you know to make it one relevant one and I think when we talked to Punita she said you know what use it however you want awesome yeah that's my question I think it was uh the Alberta videos I think videos from Punita's group correct yes yeah so Michael as you remember we had a conversation with her um and she is more than happy uh to work with CQC and actually she approached us um and I think this is a great way of leveraging um evidence-based educational materials rather than reinventing the wheel to uh use what she has created along with her team uh and Sumit thanks to you and your team for sort of um being the test case for that within the U.S. um if it works out we should also include these um posters and any other educational materials that you adapted to make and fill up through the CQC website. My second question is, it's always struck me that one of the primary faults or flaws, gaps in our management of ascites is that we'll, we see these patients every let's say two months and we adjust their direct when we see them but then we don't really have a mechanism for adjusting in between easily. You know, we get a message, a call that they're having more swelling but it's hard to know for sure. So have you guys figured out any better way of doing that? So Phillip had an idea. I think that's going to be the next phase is sort of come up with sort of a protocol, you know, here's escalation week one, week two, what to do and then everybody does a checklist. We pilot it in our group and then take it to the outreach clinics. Questions from others? I'm curious to know if you're hearing anything from patients at this point. Yes, I have been in contact with some of the patients and also the direct nurses who are taking care of patients who show up bi-weekly for paracentesis and overall the feedback has been pretty good. They would have been much happier if they would have been access to this information already a year ago they said. So especially some of them struggle in terms of nutrition, what they're allowed to eat, where to find the proper information and what actually the cause of their treatment or their disease causes and if there is actually a cure for them. These are often stated by some of their patients and I would differentiate the patient population because what I also noticed that a lot of patients who come on for bi-weekly paracentesis, these are unfortunately patients who are palliative patients or who don't qualify for a transplant anymore. So I think some of them actually lost hope and yes, I haven't come up with an idea for this patient population but yes, it's probably worthwhile to think of these patients as well. I'm also curious, you mentioned in the early stages of putting together the root cause analysis or fishbone diagram, you'd engaged with multiple staff members and I would just be interested in hearing a little bit more about how you think that helped the process and what folks' experience was being asked to engage in that process. Yeah, I can tell you a little bit about this. I mean, there were front desk manager or clinical manager who didn't have any medical background entirely and I think they were really surprised at the beginning that they were asked as well but when we go back to the fishbone sheet, you will see some issues which I was not aware of and Dr. Aswani probably either. I think they were really happy to be involved in the entire process and just to start brainstorming and they could be a part of it and to address some of this issue and I think that gave us helpful opinions of theirs. Cool. If there aren't any other questions, I think we can go on to Christina. We'll go over using the fishbone diagram and Pareto charts and another QI methodology. Okay, thank you so much for sharing that. That was really great to learn about the process you used and the approach you're taking. I actually might ask you just one more question and it's about the measurement, how you're evaluating whether this test of change or intervention is supporting increased knowledge among patients and I know that partnership you have with University of Alberta. So, are you able to access the confidence data that they're collecting and whatever measures of increased knowledge? Right now, we are in the process for the data agreement and we had a call we had a call end of September and we are in the process for the data sharement agreement and everything right now, but we should be able to access the information through webcaps and yes. Great. And I think just as a plug, I think the Michigan group has already started some work if Elliot wants to comment on that and we just want to make sure to then step on that. Any comment? Okay, it looks like there was a comment from Elliot in the chat. Okay, that the questions are being the initial validation work is underway and I think his group, University of Michigan, they've been part of that the 200 plus patients service has been done. So, I can suggestion it's been one to wait for the result of this pilot study before broadly disseminating, which I think would work in terms of the timeline for us. That's great. It's wonderful to know one great part of this group is that you learn what others are doing and putting out things that you might not think of. So, this is great. Yeah, and if I know that that sort of adds a bit of a research lens around things and thinking through with more of a quality improvement hat. I love the idea that you're thinking about measuring. What were the two things there was some knowledge and confidence and there's some good evidence around confidence to be able to manage your health condition on a scale of zero to 10. And some clinicians will use it in the course of their visit where there's evidence that if you're at a seven or higher, you're probably going to do pretty well. You have the information you need, you have the opportunities and whatever resources you may need. But if you're lower than a seven, often you need a little bit of an assist and it may be knowledge, it may be some support with motivational interviewing or other change type conversations like brief interventions. So, sometimes there's a little bit of behavioral support that that kind of question can cue you to. Okay, so I am just going to level set us with this slide and this slide you'll have seen from the August session. And what I just wanted to remind us of is that there's sort of the stages of the quality improvement process. In the beginning, we're preparing for improvement and we're doing things like defining our aim statement, which we have done. We're setting up the quality improvement infrastructure. So, we have our improvement team set up. And if for those who are newcomers to this group, this all lives in the toolkit, which Sheila will share the link to box. So, you can find, you know, what does an improvement team look like? How many members and this and that? Things like meetings, how often should we be meeting? And then things like the technical documents, you'll figure out where those live in the box as well. And that's sort of the overarching improvement objective of the CQC Learning Health Network and some of the measure specifications. As we're going, we're also talking about, and this conversation really is about theory for change. Our theory that if we build knowledge among patients, they'll be better able to manage their health conditions, better able to manage their ascites. But it's not, that's not the whole story, right? We saw the driver or the fishbone diagram with multiple aspects of the system, medical management processes, all those things. Kind of like with a theory for change, like we have a theory, we'll build knowledge. Well, I know I'm not supposed to eat half a box of Halloween candy, because it's not good for me, but I actually did do that yesterday. So, having some behavioral change supports can also complete it, making sure that the system is there to make it easier to deliver the best care, having follow up, all of those pieces. That's what the fishbone diagram helps us create. And then we also have other resources in change ideas already prepackaged in the change package. I'm going to, I'm going to remind us of that. We're thinking about what, who are our population? What are their health needs? We may be mapping workflow. So, all of these things are quality improvement processes that we can be using to better understand our system and our patients so that we can develop interventions that will meet their needs. Throughout, we're measuring, monitoring, and documenting success. We talk about testing changes, as small tests of change, what we call PDSA cycles or Plan, Do, Study, Act cycles. And this is really about helping us to introduce change in a small way over time, learning about how it works in our system and adapting it over time until we're ready to fully implement that for our entire population, or perhaps to spread that to multiple provider groups, multiple populations of individuals. So, just level setting there, I want to just remind us, of course, we don't need reminding, but this is really the improvement aim that we are focusing on today and that I'm going to anchor my conversation on. We talked about the fishbone diagram at the August meeting, and then we saw that great example of a fishbone diagram. And we also created a fishbone diagram at the August session with multiple ideas. And then we saw another really rich fishbone diagram just now. So, where does that take us? Well, currently, we have thought about root causes to the systems, and we've heard examples of how we're taking those ideas and turning them into changes and turning them into, say, patient resources to help educate patients. So, what are these next steps that we can do? Well, sometimes it's to validate and fill in gaps by speaking with staff and patients to make sure, are these the right problems that we are focusing on? And it's also sometimes to prioritize where should we begin with some of these root causes? And with those root causes, what are the changes we need to apply to overcome them? So, a couple strategies that you might be able to use to decide on next steps is, is there any low-hanging fruit when we look at these root causes? Often, you know, we get to this point, there's no low-hanging fruit. Like, if there was, it would be done by now. So, where is there consensus for change? Or maybe there's a staff member who's particularly enthusiastic about something. They've been complaining about a process for a really long time. So, we have someone who might be willing to, to champion this, to drive it forward. Is there a natural sequence to the work? So, we can start with information systems, like building the registry, but at the same time, we can be looking at things like patient self-management, as we're all doing, team-based care, how we work together, how do we coordinate care with behavioral health or primary care or community? Of course, always aligning with our own organizational priorities and values and include opinions from those who have lived experience and their caregivers. And then, another thought about deciding on next steps is using a group decision-making process. Like, I have the example of nominal group technique, that's NGT, and I briefly introduced that in August. And what I thought we could do is go through it today together. So, nominal group technique is really just a group ranking technique to prioritize problems or changes. What it is, is it helps teams come to a consensus quickly. So, if you have that really big fishbone diagram, you have all these problems, where are we going to start? It allows each of the team members to rank without peer pressure, so it can be anonymous. It shines a light on the team's consensus or maybe the lack thereof, which might need a little bit of work. And then, equal participation in the process builds ownership or buy-in of some of the next steps. So, how to do it? Let's just dig right in. This is how we're going to do it. So, I'm going to put a link into the chat box. And it's a Google Form. I'm just testing this process with everyone today. What we're going to do is vote on where we want to start. So, what you'll see when this Google Forms comes up is there's 10 root causes. The list of 10 is on the screen. And then, you can rank them in order of improvement priority from 1 to 10. So, you probably, when you open up, will have to scroll to the right to see all 10. You only get one choice of 1st, 2nd, 3rd, 4th, so on. So, I'm going to give us a few minutes to do that. But I will just say that these root causes that I synthesized here were based on the examples that we've seen today, the one that we created on Wednesday and the one that Philip went over. So, that's where some of these come from. And we're going to do this as an exercise to sort of model how we might take priorities and move them forward. What questions do you guys have? Is anyone having trouble pulling up the form? Christina, we can only pick one as number one. It's not good to pick all of them as high priority. That's right. That should be how it's set up. Yeah. Okay. So, I'm just going to give everyone a little bit of time to work through that. And I'll be able to see how many responses we have as we go. So, I've got a couple so far. I'll give a bit more time for other folks to finish it up. This is actually working really well in case you guys need to do this virtually with your teams. It's auto-populating as new entries come in. Maybe I'll share my screen so you can see what this looks like, because it's actually kind of fun. I'm just going to delete because there are tests. Anyone still working on it? I can't see faces, but 10 responses. I'll give one more minute, and then I'll process them. Anyone surprised by these I just thought maybe I should do that. Thank you. Let's see. No. Okay, so this is where the test falls apart. I don't know how to zoom in. I guess I'm surprised that one of the top ones was team not working optimally. I would have thought that it would be more structural concerns or patients or. So here's where I've ranked them, it's right at the bottom. So these are summing the total scores. So the most important would actually be the lowest number. So I've confused myself already. So it would be right because it's like everyone assigned number one for most important number so the lowest score. So 31 looks like it's the lowest. And that would be patient self-management and behavior change support. This is pretty neat. I would be interested to see if patients took this survey, how they would rank it. Yeah, that would be really interesting. Definitely something you could do at your clinic. So number two, and it's tied with access and patients don't have resources. What else do we have? 42, 43, no or limited care coordination. Anything else you're observing from this? What about like... I think it would be a good idea to also later on, Christina, maybe just give the medians. Yeah, I can definitely process this a little bit further. As we were choosing just the flipping off, either one is high or nine is low sort of thing. I think it's coming out as a surprise. I just want to make sure that we address that point. Did everyone understand that they would assign one to most important? Anyone do it differently? Okay, good. Okay, so what I think is also interesting is there's quite, when you look at any specific problem category, there is quite a bit of diversity in terms of order of importance. So we could do, what I could follow up with is a little box and whisker chart to show that spread and that variation and where the central tendency is with it, which is interesting information, not necessarily useful. Because you could do this with your own team and why that would matter is that you may have very different and potentially strongly held opinions. So after you would do an exercise like this, taking a look at that spread could be really helpful to identify if there's areas where there is quite a divergence and what people think is important, so that you make sure that everyone's moving together productively. And there's not like, well, that I didn't pick that as important. So I don't want to do that. You don't want to encounter something like that. Okay, so first is right here. I'll just label that. Second. Third. Did we have a tie for second? Yes, we did. Okay. And any close matches, 43. The next is 46. So that would be no suboptimal medication management. So I'll put that in as number four, and then I will go over to the other screen. Can you now see the table that I put together? Am I sharing the right screen? Yes. So number one was patient self-management and behavior change with examples about knowledge about how to manage condition, but maybe also support for adherence. I know there's apps and there's other different techniques for behavioral change support. Number two would be patients that don't have resources to manage their health. So maybe they're experiencing food insecurity, they don't have health insurance, transportation barriers. This one was tied with limited capacity or access to various services, labs, paracentesis, so on. Third was no or limited care coordination. And four was no or suboptimal medication management. Anything surprising in there? The top four? No. No surprises? Any reactions? No. No surprises. And I think it's consistent with what the Baylor team also found as part of their team-based assessment of root causes. Does anyone want to share how they, their thought process when they ranked these? What were you reacting to? I think it's just like, I imagine when I'm talking to my patient who has difficulty managing, it's basically what they're telling me. So it's always, sometimes I feel like they just don't understand like the adherence to diet. They don't have the knowledge there, even though we try, there's definitely room for improvement. And then the food insecurity, right? So salty food and food that's not good for you is a lot less expensive than cooking fresh at home. And so actually when I look at these types of, when I look at these results, I think about, well, okay, we can educate them more. That takes care of one of them. Maybe we can talk to radiology to make the schedule for parasitosis more accessible, but really the food insecurity and the, I think about like, how am I, how, how are we going to help that, you know? So when I look at this, I think about, well, what can we do to help fix this? But that's the one, I guess I'm kind of stuck at. So I don't know how as our clinic can help with, I'm sure there's stuff out there. I know at Boston Medical Center, they started a process where they actually set up a healthy food bank that could be given as a prescription to different patients who had food insecurity and lack of access. Cause often folks who don't necessarily qualify for a food bank, there aren't a lot of places that they can go elsewhere. So kind of setting up this really a food bank program for patients who had food insecurities, it was, it was pretty well done at Boston Medical Center. Was that with the health leads program or is that something different in-house? Let me see if I can pull something up about it and I will send it to the group. Awesome. So what to do about these things, you know, these are obviously really difficult, thorny issues. If they were easy to fix, they'd be fixed. And I think, you know, for each of these different categories, they could be their own root cause. You could dig into, it could be the source or the subject of doing some process mapping. Certainly things like finding out, you know, what, what is it that impedes a patient's ability to self-manage? Is it that access to healthy foods or is it a knowledge gap? You as providers will have some good information on that, but going to patients, asking them, even doing focus groups, surveys can really give you a lot of information about where to direct some of your early interventions or improvement tests of change. So that kind of leads to any other comments about that before we, we move forward? Okay, so then we're still on the sort of no, so now what do we do with that information? And we've just prioritized patient self-management and behavior changes, the area we want to focus on. So what can we use to guide us? We have things like conceptual frameworks, and I've listed here, it links actually quite nicely, the chronic disease or the chronic care model, which includes self-management, COM-B is another framework that was developed by some folks who synthesize the literature on what are effective behavior change interventions. They summarize the literature and created this framework called COM-B. It stands for B is behavior, C is capability. So that would be things like building knowledge and opportunity to use that knowledge to help So that's what opportunity means. Do I have the resources? Do I have access to say, this healthy food bank? If I don't have my own resources, do other people in my family eat well? So that's what opportunity means. And then motivation is more around like habits, like is this part, has this been part of my life? And, you know, what habits have I set for myself with respect to healthy eating or exercise? And so thinking about that framework can be really helpful to give us ideas about where we can direct improvement interventions and tests of change. We can, of course, always look to literature to see what ideas there are there. And that's where also we find the conceptual frameworks. We can ask patients and their caregivers, like if we have a patient family advisory council, a PFAC, surveys, focus groups, just talking to patients in your interactions with them. The confidence question can be really interesting to elucidate some of those things that people might not have access to them. There's also some really interesting work on screening for social determinants of health and asking how to ask empathic questions with patients, peers. And then we have the change package, which I'll come back to. Is there anything else like how, where else do you get ideas from? And by peers, I mean, this network and others like University of Alberta. Where else do you grab ideas from? Utilizing patient advocacy organizations and seeing how they engage patients is important. I think there's also a lot of interesting work done around addressing different vulnerabilities that exist within different communities. So those vulnerabilities that present to a patient in rural Maine are very different than those in rural Minnesota and what is already being utilized to kind of address those. Is there a healthy echo program or learning from similar institutions in similar settings? But I think really important is engaging the patient. I similarly would love to see what their response would be on the survey that we just took, because I think what a doctor's priority list versus what a patient priorities list is, is often very different and the caregiver's priorities can be very different beyond that. And how much understanding is truly occurring versus kind of that assumption of knowledge versus drilling down and really spelling it out for the lay person. Yeah, that just reminded me of another project that a colleague of mine worked on to improve with diabetic patients, their sugar control, their hemoglobin A1C levels. And so this physician had done a whole bunch of improvement work and it sort of made some improvements. The poor control was going down, which is good, the good direction. And then sort of reached a plateau and he couldn't make any improvements anymore. So he started asking his patients in the visits, how confident are you that you can manage your health conditions? And that was that zero to 10 question that I spoke about. From that, he was able to understand, is this an issue of knowledge? Is this an issue of a substance use disorder? Is this an issue of depression? So it could direct the interventions so that they would really fit based on the needs of the patient. And with that little intervention, noticed another nice improvement drop in hemoglobin A1C poor control, which is great. Any other ideas or thoughts? Okay, this group has loads of ideas. I am also going to just share briefly because it's very dense. The change package, which lives in the in box to that shared folder, the change package is really simply like just a whole bunch of ideas that may be useful as you're thinking through, what are some of the changes that you're thinking about? As you're thinking through, what are some of the changes? We need some change ideas. We could do a brainstorm with our team. Where can we look for some other change ideas? And the change package for this particular project is framed around the domains of the chronic care model. So because we pick the self-management support, I'm going to go straight to that one, to that section. But I will say that for those who aren't familiar with the chronic care model, the domains are having clinical information systems. So this domain is really about organizing your patient and your population data to be able to facilitate efficient and effective, and I would say proactive care. So you're managing the health of your populations and you have an information system to do that. And that's part of what the registry is aiming to do. Decision support are those things like flags that are based on recommendations of care. So it's really meant to promote clinical care that's consistent with the scientific evidence and with the patient's preferences. Delivery system design is, the descriptor is to assure the delivery of effective, efficient clinical care and self-management. And this one really speaks to, does everyone on the team know what they're supposed to be doing? Is the scope of practice being optimized for all of our staff members? Are our interactions with patients planned? Do they support evidence-based care? So it's really that level of organization at the team level. At the health system, this is more about sort of organizational improvement activities and culture. So it's about creating a culture and organization and mechanisms that promote safe and high quality care. So a program that adopts continuous quality improvement, that would be one with a culture and organization that drives better care. And then self-management support in lime green. This one's really about empowering and preparing patients to manage their health and health care. So we have lots of really great examples and awesome resources that I'm really grateful that team will be sharing that we can put in box to help patients understand key aspects of their disease. So this is, the topic here is really about emphasizing that patients have a really critical role in managing their health condition. You can share guidelines and recommendations, and we had those really nice examples, and there's others that are linked here. So we can build this too. Use effective self-management support strategies that include assessment, goal setting, action planning, problem solving, and follow up. So here are other interventions that you might think about, like training staff in evidence based self-management support strategies. That might be brief intervention, brief action planning, staff that have skills in motivational interviewing, and ask tell ask is just an example of a conversation based on motivational interviewing. And so again, when we think about some of these intervention, it really is about matching sort of skill to task. Who's our best team member to be doing this? How do we do handoffs and warm handoffs? Ideally, so we connect patients to members of our team that can really support their own self-management and ability to self-manage. So I won't go through the whole slide, but I just want to point out that this change package does exist, and there are a number of intervention ideas on it. Your team will have more. Knowing your own system will give you a better position to understand what will work within it, and also having patients, you'll be able to connect with them to really understand what are their needs and how can we best support them. Any reactions to this? Okay, send everyone into silence, that's good. Was it the denseness of these slides? Hopefully not. Okay, the last part of the chronic care model is about connecting with community, so mobilizing the resources in your community and often in this space, it's really about knowing what resources exist to be able to match patients to those resources as they need. So that is the change package, and now I'm coming back to the model for improvement. So for those that are new to this, it's really simple, it's just three questions in the Plan, Do, Study, Act cycle. What are we trying to accomplish? We're trying to accomplish a 10% improvement in ascites control. How will we know that a change is an improvement? We will have knowledge of our own patients, the registry, and other ways to be able to measure ascites poor control over time. As we are testing interventions like self-management support, we continue to observe those measures over time to see if it has an effect on them. And then what changes can we make that will lead to an improvement? That's from the change package, that's from what you brainstorm with your team, and from all of the quality improvement processes that you do, like process mapping and the fishbone diagram. The Plan, Do, Study, Act cycle is when we take one small piece of our change and test it to introduce it into our system in a really low risk, low workload type of way, and low threat type of way, because some changes can be a bit unnerving for staff. So that's a way to manage the change in the process, and as you develop a better confidence that those changes will in fact a better confidence that those changes will in fact contribute to what you're trying to accomplish, then you can move to implementation. So I just want to acknowledge that I shared a whole lot of content, and I want to sort of have a moment now to just think about like, what did you connect with, and what are you thinking about in terms of your own next steps? Christina, this is Jack Lake. I just was kind of curious in terms of a plan that we're looking for, are we looking for a plan that's going to apply to the entire CQC, or for our centre? The way I would think about it is, so every, all the sites like your own centre will have your improvement charter, which is aligned very much with the CQC. And so I would, I would probably direct the plan for your site level. Dr. Volk, Dr. Conwell, is that how you're also thinking about this and others? Yeah, totally. I think we all, um, we hear from other people what they've tried, we adapt it to our site, and then we share what's worked and what hasn't. That way we all learn from each other. But there may be some things that work for one site and not for others. Unfortunately, that's the problem with health services research. It's not like a pill, it's the same everywhere. One thing that I would add to that, Jack, is that as a group, as you saw, we're focusing on a site is control as something that we can potentially work, but maybe you would choose another area that needs more attention, that you need to get to faster. Yeah, that's a good point for COE. We want this work to be complementary to all the clinical administrative jobs that we all have. Jobs that we all have. And so if there happens to be something that you have been feeling like you need to tackle at your site, anyhow, that aligns with one of these measures, then fantastic. Can you kill two birds with one stone? Sounds great. Thanks. I might just also add to that as sort of the data builds and we get a better understanding of our patients and specific to this particular aim, what is our population's general ascites control levels? Even if you do find it's quite high, some sites will look at segmenting it to look for equity. Are good outcomes equitably distributed across race, across gender, across other ways that we might segment the population. So that's another thing to take a look at as well, because that can lead to specific interventions and maybe asset mapping within those particular communities. Did you hear something in the change package or maybe when Philip spoke or anything else that you're thinking like I'm kind of curious about learning more about that, or maybe I want to run that by my team. I guess there's one thing I was thinking about when you were presenting and that's we all seem to think that patient education, patient self-management is probably our number one priority in terms of area to focus on. Historically, we as healthcare providers have always heard that and said, well, then we just need to educate. We need to provide them with more information. That's usually not the answer. I mean, it can help, but in and of itself, it's not. And so I'd be interested in people's thoughts about how we can structure our healthcare delivery to motivate and empower patients and not just kind of give them information and then expect them to do with it what we want them to do. While you were talking about that, and it cued me to it earlier in the conversation, I was thinking about this model, which is another theoretical model. It's called the stuffed care self-management support model. And similar to if you're familiar with risk stratification, like looking across risks and needs in your population, something like this could help you match like, is this a, is this a learn or knowledge gap, or is this just a knowledge gap, or is this something bigger? Like, ultra-moderate alcohol use would, would warrant a brief intervention, but, you know, a substance use disorder would warrant something different again. But just thinking through the different self-management support options and matching them with the needs of the patient, this is kind of a nice model to do something like that. And I'll just drop this link into the chat. There could be some innovative ideas that could come up that we can come up with. Again, it might be a little tricky to implement or operationalize them using wearables or some other way to transfer information about patients to the healthcare systems. There are several interventions or ideas about using cell phones, for example, to review weight and, you know, what patients have had that day and using that information to also monitor and improve on SIDs. The people have implemented, they're hard to implement just because of the cost that's associated with those, but some of those ideas could potentially be, or parts of that could be something that we can try to work on. We talked about sending text messages, for example. It was mostly within the context of trying to enhance engagement with the PRO, but that could be used as a way to improve a site's control. Moving, building on what Michael said, that information is key, it's important, but it's not enough. At patient education, there are those things that we think of. Does anyone use any home monitoring programs for patients? Not outside of general, you know, home health visits, that's about it. Yeah, there have been, in the field of psoriasis, there have been a few that have been developed. There's Encephalab, there's Psoriasis Buddy, but they've not been really well validated yet, so I think there's definitely a huge need for that. Is there anyone that knows if there's staff members on their team that have motivational interviewing training or training in some of these techniques, like brief action planning or brief interventions? Not outside of our alcohol group. Our alcohol group does that. Mm-hmm. Okay, is that, I think that's all right, Christina, or were there other things that you wanted to talk about? No, that's great. Sheila, any other, can you pull up our agenda, were there any other agenda items? Let's see. Oh yeah, so onboarding new sites. I think we're hoping to start onboarding new sites in early 2022, so if you all hear of any sites, you know, I've gotten contacted by probably four or five, six sites that are very interested, and if you all hear of any other sites that you think would be good fits, please let me know. And again, the EMR integration, please all of you work on that, and it would be great to get all of you onboarded with the EMR integration soon. There's one more concept, so the next, our next learning session will probably be after the first of the year, and what we're hoping to do is a concept of a sprint, and so Christina, could you just describe that really briefly? Sure, a sprint is a more short-term but intensive type of improvement process. It would come with a specific concrete aim that each site would define locally, and then measures, a family of measures, which hopefully would be a lot, definitely aligned with the stuff in the registry, but it may also include a few additional process measures just to be able to show some progress in a short period of time. There would be a change package similar to what we talked about today, or driver diagram, essentially some key change levers that would be theorized to be the most important to achieve the aim by the end of the short term. It would be more, it would be like weekly meetings of six, 30 to 90 minutes potentially, so it's a bigger ask for, but just for a shorter period of time, and we can provide more information if there's anyone who's interested or wants to learn more. Yeah, so not all the sites will choose to participate, you know, so it may be only a few sites, but you know, if it, again, if it just happens to align with, you have some time to really focus and dive in, let's say you've been wanting to kind of dive into this and work on it, so, but we'll share more information after the first of the year. I think that was it. Sheila, Fasiha, any other things to discuss? Anyone else on the call have any other ideas, comments, questions? This is Lindsay Ventura from MGH. I have a question. I'm relatively new to the study team here, and I've just been put on this project, and I know that we're still struggling with enrollment, and I was just wondering if there's an opportunity to speak to other sites about kind of modes that they've taken with enrollment with a recognition for unique challenges in patients who have cirrhosis. Maybe they have AG, and they have difficulty engaging with new tech. Are folks doing questionnaires over the phone? You know, how are we getting the responses, and kind of what additional things might we be able to implement here to really up our enrollment and response rates? Yeah, great question. So, I think, Sheila, what's the best way for everyone to get everyone else's contact information? I think you've been creating an Excel sheet. That's in Box, right? It's in Box as well. So, I will send this Box link out again. But if, I mean, if we have a few minutes, if anybody wants to share anything with Lindsay while we're still on. What has worked for your team? I can just summarize, because we've heard on prior sessions, we've heard from multiple sites. We learned about that. So, you know, like we, some sites will have the clinic list review ahead of time, identify patients or potentially candidates, put in reminders, either on the desks of the providers or in the schedule, like in the comments on the actual schedule. Having flyers in the waiting room, we created a flyer. For patients to be able to say, oh, hey, I'm interested in this. And they bring it in and hand it to their provider. I think a lot of sites have been using iPads to have patients fill out the questionnaires in clinic, since, you know, they might sign up and agree to it. But, you know, they'll know won't forget about it and not do it later. Other things that have worked for other sites? I'll follow Sheila's links and connect with some coordinators who have had success. I don't want to reiterate things that have already been discussed over, but I really appreciate it. And I'm excited to be joining the team. Okay. Well, thank you, everyone. I have a quick question. We have a question about a technical problem. So, for the CQC upper metrics logging. So, there is like a one-time passcode for through dual mobile. So, is there anybody I can go to? Because I changed phone and I can't switch it to my new phone for the access. And I was not able to find any access code or activation. So, just wondering whether anybody, I think I emailed somebody earlier, but I didn't get a response. Can I ask your name? I'm not sure who's speaking. From University of Minnesota. Mercury. Okay. Yeah. I will follow up with Andy for you because I had the same issue where I switched phones and then you have to do the QR code thing over again. So, I will. Okay. Thank you. So, for things like that, it's Andy Urkanian with Arbor Metrics and Sheila can connect you if you don't have this contact information. Okay. All right. Thanks, everyone. Thank you all. Bye.

ASLD

patient care

cirrhosis patients

patient education

QR codes

data collection

educational interventions

ascites management

problem-solving

patient empowerment

electronic medical records

patient enrollment

Mickey

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