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Team Meeting Checklist

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TEAM MEETING CHECKLIST (1st TEAM MEETING OF BLOCK)

1. CHECK-IN

2. SIGNOUTS: Review signouts from last team and any potential team coverage issues

3. QI REVIEWS: PGY2 quickly reviews QI focus - remind group what projects and where we are in QI cycle

4. WEEKLY PATIENT CARE GAP REPORT REVIEW

5. MONTHLY QUALITY REPORT/PANEL MANAGEMENT:

Address PANEL SIZE outliers (Targets: PGY1 60-90, PGY2 70-100, PGY3 80-110)
- Interventions for LOW panel size: Acquire patients as appropriate (eg urgent patients with no PCP, patients with no clear PCP, etc). Ask firm’s urgent care providers to refer new patients or those not engaged in care.
- Interventions for HIGH panel size: Assign new patients to residents on team with small panel.
Address CONTINUITY outliers (<50%)
- Improve follow-up after visit
  - Discuss follow-up plan explicitly during precepting
  - Use follow-up scheduling dotphrase (resident—in AVS; attending—in cosignature)
  - At the end of the session, verify that follow-up appointment was scheduled, and, if not, ask Firm Front Desk Lead to call patient to schedule.
  - (Second team meeting of the block, review IMA Resident Return Appointment Availability report to determine % appointment slots filled for next block- goal = 70%; if < 50%, resident should outreach their patients to fill slots)
- Conduct outreach
  - Run Epic report “My Patients for Whom I am PCP”.
  - Identify up to 5 patients previously seen by PCP (date in “Last Appt with Me” column) without an upcoming appointment (no date in “Next Appt with Me” column).
  - Send list to Firm Front Desk Lead, along with PCP availability (using dotphrase), cc’ing team preceptors.
Address CLINICAL QUALITY MEASURES:
- Identify and discuss best practices used by top 10% performers
- Care gaps: Each resident chooses 1 of the measures below (select a measure associated with performance in the bottom 25%, if applicable) and identifies 3 patients for outreach (patients not scheduled for an IMA appointment during the current block)
  - Mammography: 1) Run report “My Female Patients 50-74 W/ Overdue Mammogram Health Maintenance” 2) Call the patients with instructions for scheduling a mammogram and place the order as an addendum to a previous encounter
  - Cervical Cancer Screening: [Workflow on hold. To view patients in need of cervical cancer screening, run report “My Female Patients > 21 W/ Overdue Cervical Cancer Screening Health Maintenance”]
  - Colon Cancer Screening: 1) Run report “My Patients 51-80 w/Overdue Colorectal Cancer Screening (PCP)” 2) Order Screening colonoscopy or Cologuard as an addendum to a previous encounter and send a staff message to Mike Guzman, who will assist the patient with colonoscopy scheduling or Cologuard orientation.
  - A1c outlier: refer to Diabetes Educator (send staff message and place order for Diabetes Alliance if the patient has not seen a diabetes educator in the last 12 months)
  - Uncontrolled HTN: refer to Clinical Pharmacist (send staff message)