Phase 4. Continuously Improve Performance and Sustain Changes

Key Change 4.1. Reexamine Your Outcomes and Make Adjustments for Continued Improvement

Real practice improvement means being committed to change, and that means planning for challenges even when you're succeeding. Generally, practices see great improvement in the first months of practice redesign, and they are tremendously motivated by those improvements. But inevitably those improvements start to plateau. The key is not allowing setbacks to halt your efforts. Continue to go back and evaluate your clinical, financial, and operational goals and strive for improvement. This constant reevaluation requires organizational commitment to ongoing improvement, but it is the only way sustainable change can be realized. Remember, improvement is a journey, not a destination.

There is a whole community of safety net practices who have gone through what you're going through. Look for ways to connect with those groups, and learn what they did to sustain their improvement efforts.

In addition, we've provided a number of tools below that can help to keep you motivated and focused on improvement. One such tool is the Change Flow Chart. This tool helps practices reflect on their results and then prompts them with specific questions to continue their improvement journey. The rest of the tools can be used within the context of the Change Flow Chart to keep focused on long-term financial sustainability and clinical improvements.

Actions	Tools
Overcome barriers to improvement.	Change Flow Chart (guide)62
Apply process mapping methodology to new processes to ensure efficiency and sustainability.	Primary Care Practice High Level Flowchart (worksheet)63
Continue to optimize clinical interactions.	Plan Do Study Act Worksheet64
Work with community resources to ensure access to services that may not be available in house.	How Hot Are Your Improvement Action Plans PDSAs (worksheet)65 Community (presentation)66

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Key Change 4.2. Capture Incentives Based on Quality of Care

Evidence remains mixed about the ability of pay-for-performance programs to change health outcomes by themselves. However, incentives can serve an important motivating and sustaining function when used as part of a robust quality improvement program.

Many health plans and other organizations are working on quality incentives, so maximize your revenue by taking advantage of those certifications, grants, and programs that tie into your Chronic Care Model work.

In addition to responding to pay-for-performance programs from payers, staff-model organizations also have an opportunity to structure their pay packages to create quality incentives for their staff. A few safety net provider groups have tried restructuring benefits to incentivize quality improvement. Learning from their experience could be helpful for sites interested in pursing this strategy. Also, take a look at the Agency for Healthcare Research and Quality's Pay-for-Performance guide to learn what factors health plans take into account when designing their pay-for-performance programs.

Actions	Tools
Pursue opportunities for enhanced reimbursement through grant funding as well as your payer's pay-for-performance and accreditation programs.	Pay For Performance: An Introduction (guide)67
Contact leaders in the field who have successfully leveraged these opportunities and learn from them.	Go to "Stories from the Field" section
Learn what purchasers consider when developing a pay for performance program.	Pay for Performance: A Decision Guide for Purchasers (guide)68

Additional Resources

• The National Association of Community Health Centers, http://www.nachc.org, conducts numerous trainings on grant writing and billing and coding, and they can connect you with a large network of other community health centers involved in quality improvement work.

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