Division of Women’s Health Quality Assurance / Quality Improvement Process February 21, 2013

1. Division of Women’s Health Quality Assurance / Quality Improvement Process February 21, 2013

2. Mission Statement The Division of Women’s Health promotes preventative healthcare in partnership with local agencies by providing education, facilitating access, and assuring quality services in the areas of breast, cervical and ovarian cancer, family planning, preconception care, and adolescent health.

3. Grant Requirements Both the Kentucky Women’s Cancer Screening Program (KWCSP) and the Family Planning (FP) program have grant requirements that a system be in place to provide for ongoing evaluation of program personnel and services.

4. Quality Assurance Quality Assurance (QA) is a systematic process of monitoring the delivery of services to ensure established standards are met and to ensure compliance with standards of practice as well as applicable state and federal regulatory requirements. 

5. Quality Improvement Quality Improvement (QI) involves the implementation of changes in processes or procedures to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality in services.

6. QA/QI History – KWCSP The KWCSP QA/QI requirements have been met through internal audits conducted within the service sites as well as site visits conducted by the KWCSP staff.

7. QA/QI History – Family Planning FP program QA/QI requirements were previously met through internal audits conducted within the service sites as well as site visits conducted by the Quality Improvement Team (QIT).

8. Change in Process • In 2012, the QIT was disbanded leaving a need within the DWH for a revision in the QA/QI process. • Jim Rousey with the Center for Performance Management (CPM) facilitated a workgroup comprised of Local Health Department (LHD) staff and DWH staff to develop a new QA/QI process within the DWH.

9. Workgroup Findings Needs identified: • Decrease duplication of the QA/QI process among DWH programs; • Increase the effectiveness and efficiency of the QA/QI process among DWH programs; and • Provide a consistent QA/QI process across the state for DWH programs.

10. Workgroup Determinations • The QA/QI process for the DWH should be consolidated to meet the needs of both the KWCSP and the FP program. • A new QA/QI Policy must be developed for the DWH. • Tools must be developed to support the new DWH QA/QI Policy.

11. Policy / Tools Development Process The DWH QA/QI process workgroup divided into two subgroups: • Policy Development Team • Tools Development Team

12. Policy The DWH QA/QI process focuses on the requirements of the DWH programs including the KWCSP and the FP program. QA will be monitored through three components: internal audits, desk audits, and site reviews. In addition, DWH staff provide ongoing training and technical assistance to all clinic sites providing KWCSP and FP program services.

13. Internal Quality Assurance Audits LHD Responsibility: • Review KWCSP Minimum Data Element (MDE) reports and MDE Audit Reports monthly. • Perform quarterly internal quality assurance audits of the KWCSP and FP program services provided by the agency at all clinic and subcontracted clinic sites.

14. Internal Quality Assurance Audits Continued • LHDs that are “assuring” KWCSP and FP program services at a subcontracted site are responsible for auditing those service sites and must include language regarding this requirement in the contracts with those providers.

15. Internal Quality Assurance Audits Continued • The internal QA process includes an assessment of the KWCSP and FP program services provided by the agency including a chart review of medical records. • The findings, interventions implemented, and progress toward goal(s) shall be documented on a reporting tool provided by DWHand submitted to the DWH annually.

16. Desk Quality Assurance Audits DWH Responsibility: Complete desk audits of each of the LHDs to include:  • Quarterly: - KWCSP - Minimum Data Element (MDE) reports and MDE Audit Reports - FP program - Sterilization Reports

17.  Desk Quality Assurance Audits Continued • Annually: - LHD Internal Audits - LHD FP Information & Education (I&E) Committee Meeting Minutes

18. Quality Assurance Site Reviews Performed by DWH staff – DWH staff will complete targeted QA/QI site reviews of each of the LHDs at least once every 2 years.

19. Quality Improvement Technical Assistance DWH staff will conduct an Interactive Videoconference (ITV) quarterly to provide training and technical assistance to LHD staff regarding KWCSP case management and DWH program issues.

20. Contact Information Melody Stafford, RN Director, Kentucky Women's Cancer Screening Program Division of Women's Health (502) 564-3236 x 4031 Fax:(502) 564-1552 Melody.Stafford@ky.gov Emily Adkins, RN Nurse Consultant & Interim Director, Family Planning Program Division of Women’s Health (502) 564-3236 x 4163 Fax:(502) 564-1552 Emily.Adkins@ky.gov

21. Contact Information Deborah Donovan, RN QA/QI Auditor, Division of Women's Health (502) 564-3236 x 4157 Fax:(502) 564-1552 Deborah.Donovan@ky.gov Gina Reid, RN QA/QI Auditor, Division of Women's Health (270) 404-1215 x 4163 Fax:(502) 564-1552 Regina.Reid@ky.gov Carolyn Kerr, RN QA/QI Auditor, Division of Women's Health (502) 564-3236 x 3753 Fax:(502) 564-1552 Carolyn.Kerr@ky.gov