The IHC Compass PTN is a monthly email featuring success stories, TCPI updates and other local/national educational resources.
February 20, 2017
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Welcome to the Compass Practice Transformation Network Newsletter! We give clinicians the support and tools needed to thrive in value-based care.
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The 2017 Transition

It's go time. With the first QPP performance year underway, it's time to transition to value-based care. Whether you've begun collecting performance data, or are waiting for the whole thing to just go away, here are a few tips to test your knowledge about MIPS.
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Person and Family Engagement Web Series 

As we continue to strive towards providing the best quality care and patient safety, the role of the patient, their family, and/or caregivers cannot be understated.   Person and family engagement (PFE) is not only a primary driver for transformation, but can be the difference between patients able to successfully manage their health conditions and patients who are unable to achieve control, leading to the potential for adverse events, hospital admissions and readmissions, and increased total cost of care.
Within Compass, we are committed to assisting our clinicians to not only improve clinical best practices and outcomes, but to support opportunities to better engage our patients and their families and caregivers at all levels – in direct care, in policy and protocol, and in greater governance and leadership.
Join us on Tuesday, February 28th at 11:30 a.m. as we kick off a series of PFE virtual education events.   During these events we will talk about the latest in the PFE movement within TCPI, including metrics, measurement, and best practices. 
Click here to register
CMS QPP Portal Testing Request 

CMS is interested in the feedback of TCPI enrolled clinicians to test the QPP Portal:

1. CMS is looking for names of clinicians who would commit to gaining immediate access in a yet unreleased version of the QPP portal designed to;
  • Validate engagement of a public eligibility tool based upon NPI look-up
  • Validate engagement of a personalized account which does not yet include practice managers, office managers, or other staff authorization (i.e. surrogacy configuration)
  • Validate the data acquisition & load process
  • Gauge user reaction to seeing real eligibility data to identify volume, degree, and type of data issues anticipated once eligibility letters are disseminated, NPI look up made public, and authentication provided
  • Provide advance development of training and service center staff
  • Validate top questions and triaging process 

2. This next version of the Quality Payment Program portal includes a new website tool to help Medicare providers understand their program eligibility by simply providing their NPI number.  Additionally, QPP is developing a more personalized account whereby providers can login to the website and learn even more about their detailed eligibility, special status, and APM participation. 

Contact Katie Pfadenhauer at
Clinician Engagement

Physician engagement is essential to transforming from volume-based healthcare to value-based healthcare. The practice environment is a very busy place and many clinicians along with staff feel they do not have time to work on quality or that it adds more work to the already full workload. Quality improvement initiatives can actually decrease workloads and disperse amongst the team members, increase time with patients, and provide quality care to the patients while decreasing times. Quality improvement work takes engagement at all levels but to sustain change, the clinician must be involved in the change. If clinician engagement is low at your practice, please contact your quality improvement advisor to help with engagement. Compass PTN has clinician faculty specifically trained to help with clinician engagement who can come on-site to lead the discussion of engagement.
Quality and Resource Use Report
The QRUR report cards are out for 2015, the report helps practices and clinician’s asses their quality of care given and the cost of that care. Please see Figure 1 below to see how costs are calculated. Costs will not be calculated in year one (2017) of the QPP but the following years costs will be based on claims data. To help you prepare, Compass PTN is asking for you to start sharing your 2015 QRUR reports with your quality improvement advisor. The PTN’s intention is to help you understand your scores, report cost savings, and help you reduce costs in preparation for 2018. The information shared with the PTN is kept confidential and numbers are never attributed to an organization. You can share your QRUR with your quality improvement advisor or you can share top priority items from 2015 Annual QRUR (top priorities)
  1. Exhibit 5-AAB
  2. Exhibit 5-BSC
  3. Exhibit 3-CCC-B
  4. Cost Composite Score
  5. Value Modifier Score
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The Phases of TCPi
Clinics participating in the Transforming Clinical Practice initiative must move through 5 phases of TCPi before they are fully prepared to thrive as a business in a value based climate.  The phases include: Phase I-Set Aims, Phase II-Use Data to Drive Care, Phase III-Achieve Progress on Aims, Phase IV-Achieve Benchmark Status, and finally Phase V-Thrive as a Business via Pay-For-Value Approaches. 
CMS expects that all clinicians who have enrolled in TCPi before October of 2016 will complete Phase I prior to March 28, 2017.

Phase I-Set Aims:
  • Enroll your practice in TCPi
  • Complete a baseline practice assessment utilizing the Practice Assessment Tool (PAT) and a follow up PAT every 6 months.
  • Use the information from the PAT and the TCPi Change Package to complete a Transformation Plan. 
  • Identify quality measures that you would like to report.  One measure must be chosen from the Compass PTN Core Measures.
Do you know what phase your practice is in?  If you have not completed a Transformation Plan, please contact your Quality Improvement Advisor (QIA). 
Sanford Health Holds First Nurse-led Annual Wellness Visit

Sanford Health has a team care initiative that is striving to creatively provide care to patients by encouraging all staff in the clinic setting to work at the highest level of their scope of practice.  Over the past several months, the Sanford Health Bismarck 7th & Thayer Internal Medicine team has diligently worked to make nurse-led wellness visits (AWV) a reality

Staff identified patients that would be appropriate for the nurse-led AWV and created a scheduled slot on Thursday afternoons.  The very first nurse-led Annual Wellness Visit (AWV) in the Sanford enterprise was completed December 8, 2016.  This appointment used a clinical team of two RNs and a CNA with assistance from the RN Supervisor

The visit was a huge success.  During a follow-up telephone call, the patient stated "I prefer the nurse do the visit.  They did a great job.  I will do this again next year."  Patients participating in these nurse-led AWVs have rated the visits 10:10. 

The internal medicine team has set a goal to see a minimum of two nurse-led AWVs each month in 2017.  Nurses continue to identify patients as candidates for this successful new visit type.  
Northeast Georgia Physicians Group Finds Success

The Northeast Georgia Physicians Group joined the Compass PTN in August of 2015 with the goal of working on their top box scores and providing the quality of service needed to in order to increase their patient satisfaction.  NGPS is a large organization with a quality department, and had been going through some patient quality transformational changes processes prior to joining the Compass PTN.  Lee Hix, Practice Administrator with NGPG, said this put them ahead of the curve in terms of making quality improvement changes.

One of the NGPG’s aims they set going into the process was decreasing lead time, the amount of time a patient spends in the office.  NGPG worked to cut out triage rooms and eliminate a check out area to decrease both patient movement throughout the office and lead time.  They were able to decrease patient lead time by 47% in their clinics and said patient satisfaction with the process has been overwhelming.  The decreased lead time significantly cut down patient apprehension with going to see the physician. 

NGPG’s most impressive success with the program has been a decreased average wait time within the clinic.  Prior to joining Compass PTN only 24.2% of their patients had a wait time of 15 minutes or less.  Currently 74.98% of patients have a wait time of 15 minutes or less. 

NGPG faced many challenges during their transformation, with the largest hurdle being provider standardization.  Mr. Hix said they worked with providers to standardize every aspect of a patient's visit.  This enabled any nurse to work with any provider, which was not able to happen prior to the standardization process.  The standardization process also cut down on unnecessary tests.  Since joining Compass PTN, NGPC has seen a dramatic increase in provider, employee, and patient satisfaction. When asked for advice for clinics just starting the process, Mr. Hix said “with any new program there are definite pain points, but I encourage clinics to bear with the pain points, view problems as treasures and they will be successful.”
"Secret Patients" Provide Feedback to Ottawa Family Physicians 

Ottawa Family Physicians in Ottawa, Kansas have found an effective tool to get patient feedback.  “It’s just very simple,” said Betty Franklin, administrative assistant. 

Franklin explained that two or three weeks ahead of time, they look through the patient schedule and randomly pick three or four patients.  A staff member calls them and asks if they would be willing to be a “secret patient.”  If they agree, a Patient Satisfaction Survey is mailed to them, along with a self-addressed, stamped envelope. 

After their appointment, the “secret patients” fill out the survey and mail it back.

“We get feedback on how their visit went.  They might name specific employees or tell us about anything from the front office to ancillary services.  The feedback is usually positive. Any complaints are usually about the wait time,” Franklin said. “We go over the surveys in staff meeting.  If an employee who stands out is identified, we give them kudos.”

As a thank you for their participation, “secret patients” receive a gift card to Walmart or a local merchant. 

Ottawa Family Physicians comprises seven physicians and three nurse practitioners. They have been using this simple tool for four or five years and plan to keep it going as an easy way to gain valuable feedback from their patients.                                                                                                            
Sanford Health Improves Colorectal Cancer Screenings in 2016

Five Sanford Health Family Medicine Clinics in the Sioux Falls Region have set a goal to improve colorectal cancer screening rates to 80% by 2018.  The Sanford Family Practices at 69th & Minnesota, 26th & Sycamore, 4th & Sycamore, 49th & Oxbow and Brandon have implemented evidence-based strategies using a team care model.  All five clinics made gains in their CRC Screening rates in 2016

Read More.

Support and Alignment Network Spotlight: Choosing Wisely

Advancing use of Choosing Wisely in the clinics will increase physician engagement in their health care transformation and improve patient and family engagement in their medical care throughout the PTN. The overall goal of Choosing Wisely is to avoid waste, reduce unnecessary medical testing, treatments, and procedures by providing open communication between provider and patients guided by evidence based recommendations.  

Compass PTN Data Submission Schedule 

Data should be submitted monthly through Compass PTN Portal:

Each enrolled clinic has received an email from the Compass PTN Portal with login instructions. If you need assistance, please contact the Portal support desk: (800) 679-7351 or email You may also contact your Quality Improvement Advisor for assistance as needed. Each clinic will be expected to enter data on at least one measure each month.

Learn more

Calendar and Events

Understanding and Promoting the Value of Chronic Care Management Services Call
February 21, 2017
Follow this link to register.

Beyond Projects and Programs: 5 Steps to Patient-Centered Culture Change
February 22, 2017
Follow this link to register.

HCDI SAN Educational Series Webinar: "Electronic Health Record (EHR) Optimization: 5 Tips to Optimize Use of Your EHR and Get Your Time Back"
February 22, 2017
Follow this link to register.

Practice Facilitators Role in Engaging Clinicians and Practice Teams
February 23, 2017
Follow this link to register.

NRHI SAN: Designing and Evaluating Quality Improvement Programs
February 23, 2017
Follow this link to register.

Academic Peer Group Webinar
February 27, 2017
Follow this link to register

Person and Family Engagement 101 Webinar
February 28, 2017
Follow this link to register

Childhood Obesity in the Primary Care Office: An Overview of Assessment and Management
March 30, 2017
Follow this link to learn more and register

Compass PTN Learning Community
April 6, 2017
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 The Compass Practice Transformation Network is supported by Funding Opportunity Number CMS-1L1-15-003 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the views of the U.S. Department of Health and Human Services or any of its agencies.

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