PHASE Onboarding Playbook: QI/Team Lead

What QI Managers and PHASE Team Leads Need to KNOW

• PHASE is a population health management program developed by Kaiser Permanente  that reduces heart attacks and strokes for patients at elevated risk with medication and lifestyle changes.
  Learn More: Participant’s Guide to PHASE, PHASE on a Page
• The initial focus of PHASE is HTN control, followed (in many agencies) by interventions for diabetes, smoking, BMI, and depression. There are 14 measures that are tracked on a quarterly basis. The outcomes tracked are consistent with those from the HEDIS (Healthcare Effectiveness Data and Information Set) standardized performance measures.
  Learn More: PHASE Reporting Template
• PHASE offers a means to build capabilities and reengineer care processes in your agency; the model can be duplicated for other services and initiatives, and can be adapted for provider onboarding in general.
  Learn More: Building Blocks Summary
• KP’s support for PHASE includes training classes, peer learning, clinical expertise, coaching and customized technical assistance.
  Learn More: Participant’s Guide to PHASE
• PHASE is usually led by a QI staff person. Successful implementation of PHASE requires:
  • leadership support
  • strong input and participation from a clinical champion
  • committed multi-disciplinary team

  Learn More: Participant’s Guide to PHASE

• Teams require regular, accurate data to close care gaps. These data include performance on the targeted measure(s), lists of patients in need of outreach, pre-visit planning/huddle reports and other registry reports on care gaps.

What QI Managers and PHASE Team Leads Need to DO

• Define and reinforce benefits of PHASE participation at organization, care team, and patient level.
• Convene a team responsible for improving hypertension care; include representatives from data analysis, operations, clinical, quality and a liaison to leadership.
• Deploy a systematic QI approach with your team and other stakeholders to analyze current care processes, review known best practices and identify PDSAs on improvements. Prioritize improvements and implement via PDSAs.
  Learn More: CDS/QI Worksheet
• Submit data report to evaluation team (CCHE) quarterly; work with departmental data stewards to ensure high quality data. If participating as a health center in a consortium, you will submit data directly to your consortium.
• Identify team members to meet with the evaluation team (CCHE) quarterly to discuss data and reflect on changes. Consortia grantees will meet with the evaluation team on behalf of health centers participating as part of a consortium.

• Make sure the right people from the organization are taking advantage of PHASE learning and support opportunities.
• Ensure the team has accurate, complete, and timely data to measure progress and make improvements and stay motivated.
• Document the team’s work and share progress with leaders and encourage celebration of the program’s outcomes and successes.

Download Know/Do as PDF