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Quality Improvement at Your Health Center

Quality Improvement at Your Health Center. Dr. Genevieve Brauning Hawgood Angela B. Allen, MA Associate Director of Administrative Services UNC Charlotte Student Health Center. Learning Objectives. Compare PDSA and AAAHC 10-point QI Rubric Discuss implementing a QI initiative

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Quality Improvement at Your Health Center

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  1. Quality Improvement at Your Health Center Dr. Genevieve Brauning Hawgood Angela B. Allen, MA Associate Director of Administrative Services UNC Charlotte Student Health Center

  2. Learning Objectives • Compare PDSA and AAAHC 10-point QI Rubric • Discuss implementing a QI initiative • How to get people interested • How to identify areas for QI • Demonstrate a QI study, step-by-step • Discuss the importance of follow-up

  3. Outline of Our Talk • What is Quality Improvement and why is it important? • QI Acronyms • The Task of Quality Improvement • Getting Buy-in and Finding Topics • Models of Quality Improvement • PDSA • AAAHC 10-point Model • Pap Smear Guideline Adherence at UNC Charlotte’s Student Health Center

  4. Quality Improvement Acronyms TQM RCA OMG Six Sigma PDCA FADE or PDSA or DMAIC CQI

  5. The Task of Quality Improvement • Quality improvement programs are not just to pacify accreditation associations. • The purpose of QI in a health care setting is to improve patient outcomes. • The important components are: • Identifying issues or areas in which the organization is lagging behind goals or benchmarks, • Implementing corrective actions, • Ensuring they have the desired impact, and • Communicating these results to stakeholders.

  6. Getting Buy-In & Finding Topics • Why do we have to do this? • Everybody gets annoyed when processes don’t make sense • Employees like to have a say in policies & procedures • Numbers help make your case • Which kind of spiral do you want? • Accreditation bodies make you! • Finding Topics • Use your QI Committee members • List of possible topics

  7. The PDSA Model

  8. AAAHC 10 Point Model • 10 simple, and acronym-free, steps • Structured framework for identifying problems, crafting solutions, and following through with implementation • Compare data to benchmarks and performance goals. Is there really a problem? No? Back to step one. • Identify and implement corrective actions. • Re-measure. • Goals met? If not, go back two steps. • Communicate findings. • State your problem and explain why it is important. • Identify measurable internal and/or external benchmarks. Set performance goal. • What data will you collect & how. • Collect data and describe. • Analyze data.

  9. Step One: State Your Problem • Can’t find a problem? • Some places to look: • Work flow and wait times • Patient satisfaction • Staff morale • Follow up and/or tracking problems • Problems identified in peer review • Disease management • Adherence to treatment guidelines

  10. Pap Smear Guideline Adherence:What was the problem & why was it important? • Historical practice of providing Pap Smear to sexually active women, regardless of age. • November of 2009, new guidelines published by The American College of Obstetricians and Gynecologists. • Suspected that unnecessary Pap tests were still being conducted at the Student Health Center. • Importance of new guidelines in reducing false positives, unnecessary tests & trauma.

  11. Step Two: Benchmarks & Goals • Where to find Benchmark data: • Internal data sources • EMR • ACHA-PSAS or other patient satisfaction survey • External data sources • CORE or NCHA • ACHA Benchmarking Committee • Centers for Disease Control or State Health Department • http://www.health.ny.gov/statistics/chac/national.htm • Participation in surveillance networks • Setting a realistic goal

  12. Pap Smear Guideline Adherence:Our Benchmarks and Our Goals • Our external benchmarks: • From the Centers for Disease Control: • In 2000, 76.4% of women aged 18-21 had received a Pap Test • By 2010, this number had dropped to 52.5% • From the University of Virginia College Health Surveillance Network (CHSN): • National data from the 2011-2012 academic year indicated that only 2% of women under 21 were receiving Pap Tests • In the southern region, 3.71% were receiving Pap Tests • Our internal benchmarks: • Pulling data from January & February 2011, we found that 23 women under age 21 scheduled pap test. Of these, 21 of them received a pap (91%), so we were at an abysmal compliance rate of 9%.

  13. Pap Smear Guideline Adherence:Our Benchmarks and Our Goals • Our Goal: • Clearly, we had a long way to go! • We were nowhere near either CDC, national, or regional benchmarks. • We set a lofty goal of 95% compliance (only 5% under 21 receiving unneeded pap tests) • This was a big goal, given our current compliance, but was actually a bit under the CHSN benchmarks.

  14. Step Three: What do you need to know? • What data do you need to collect? • Is aggregate data sufficient or do you need to drill down to certain demographics • Can you just look at the numbers, or will you need to review individual records? • Where are the data? • EMR • Internal Survey • In your paper file storehouse  • How will you collect them? • If you have EMR, do you know how to pull the reports? • If you don’t, do you have willing data geeks? • Who will collect them? • Do you just need data folks or do you need a clinical person to review the files?

  15. Pap Smear Guideline Adherence:What we needed and how we got it • We needed: • Number of women under 21 who were scheduled for P&P at the Student Health Center. • Number of women under 21 who received pap tests at our facility. • If any of the women under 21 receiving a pap had a medical history that would justify it. • This was not just a data driven report, it required a clinical review • This is why the time frame for our internal benchmark was so limited.

  16. Step Four: Collecting the Data • Run the reports • Describe the data you pulled • Don’t try to analyze at this step, just tell your audience about what you have.

  17. Pap Smear Guideline Adherence:Our Data • For our internal benchmark, we had pulled a report from January and February of 2011. • For our first data point, we pulled the same report for January & February of 2012. • There were 34 women under 21 scheduled for P&P appointments during this time frame • Of these, 8 women actually had pap tests done. • None of the 8 had a medical history that would indicate a pap test.

  18. Step Five: Analyze the Data • Could be as simple as percentages • Could need to break out by demographics • Could need to enlist the help of your resident stats geek

  19. Pap Smear Guideline Adherence:Our Analysis • For our study, we were just dealing with percentages so there wasn’t much analysis to do. The bulk of the work was in reviewing each file for important history. • So, 8 out of 34 women under age 21 had a pap done despite the fact that there was no medical reason for doing a pap. • This is 23.5% receiving an unnecessary pap, or 75% compliance with the guidelines.

  20. Step Six: Compare to Goals • Do we have a problem? • Not all hypotheses are correct • “No problem” is still a valid finding • If no problem: • Pat yourself on the back for doing a good job • Go back to step one • If there is a problem, congratulations! You’ve found something useful to try to fix. • Move on to Step Seven

  21. Pap Smear Guideline Adherence:Did we have a problem to correct? • Our goal, based on our benchmarks was 95% compliance. • Although our compliance had increased dramatically from 2011 (9% compliance) to 2012 (75% compliance), we were still short of our goal. • So, yes, we had a problem that needed to be addressed.

  22. Step Seven: Corrective Actions • The time to brainstorm about solutions is when you know you have a problem • Now that you’ve identified the issue, what do you think might work? • You have an idea? Give it a shot! • Implement ONE corrective action at a time

  23. Pap Smear Guideline Adherence:Our corrective action • We believed that the problem was clinic-wide. • The guidelines were a dramatic departure from conventional wisdom. • We decided that the best way to combat this problem was to design a training: • What are the guidelines? • More important, why? • What is the danger of continuing as we were?

  24. Step Eight: Re-measure • You implemented one corrective action • You gave it some time to work • Did it work? • Re-measure • Collect data again, like you did in step four • Analyze again, like you did in step five

  25. Pap Smear Guideline Adherence:Our second collection of data • Dr. Brauning presented the training to our entire staff in March of 2012 • In April of 2012, we ran another report to see if there had been any changes in the incidence of pap tests for patients under 21. • Between 4/1/2012 and 4/30/12, 41 patients under the age of 21 were scheduled for a P&P. Of these, only 7 were given a pap test.

  26. Step Nine: Goals Met? • You implemented a change& gave it some time • You re-measured and analyzed again • Did it work? • No? Back to step seven and brainstorm another intervention • Yes? Congratulations, you’re almost done!

  27. Pap Smear Guideline Adherence:Did we meet our goals? • So, out of 41 women under 21 that were scheduled for a P&P, only 7 had one (7.3%). • This meant that we were now at 92.7% compliance. • We were climbing, but we weren’t there yet. • Back to Step 7

  28. Pap Smear Guideline Adherence:Step 7: Part two – Back to Brainstorming • The Problem: • Providers understand the guidelines • Maybe, as we thought originally, the students are part of the problem. • Time to educate the students. • The Solution: • Create an information sheet for students. • Create a checkbox in EMR that documents provider review of info sheet with students.

  29. Pap Smear Guideline Adherence:Step 8: Part Two – Re-measure … Again • We felt that the student education piece might take a bit more time to work. • We also wanted to wait until we could compare the same time frame as we had used in the first two reports. • For our 3rd data point, we pulled the same report as before for January & February of 2013

  30. Pap Smear Guideline Adherence:Step 9: Part Two - Did we meet our goals? • During January & February of 2013, 61 women under 21 were given an appointment for a P&P • Only 4 received a pap test • Of these, 3 women had a history of abnormal pap tests. So there was only one pap test given that didn’t conform to the guidelines. • This is 1.6%, equating to a compliance rate of 98.4% • Did we meet our goals? • YES!! • Finally, on to Step 10

  31. Step Ten: Communicate Findings • You worked hard • You got results • Make sure somebody knows … make sure everybody knows! • Who needs to know? • Employees • Supervisors • Management Team • University Leadership • Accreditation Organization

  32. Pap Smear Guideline Adherence:How we communicated our success • Management Team has been on board with this process from the beginning • However, once these goals were met, the communications needed to be expanded: • Staff were informed via a congratulatory email • Management team was informed of the final success of the project • The university will be informed on our annual institutional effectiveness report • We are informing you

  33. Questions

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