Sponsored by the National Association of Community Health Centers

1. Sponsored by the National Association of Community Health Centers Presented By Shoreline Health Solutions, LLC Trudy Brown Ripin, MPH President & Founder Molly K. Gwisc, MPH Associate Implementing Quality Improvement Activities at Your Community Health Center

2. Components of PI Program Proactive / preventative strategies Before something goes wrong • Peer Review • Chart Completeness • High Risk Procedures • Patient Satisfaction Reactive / responsive strategies After something goes wrong • Patient Complaint Response • Incident Follow-Up • Sentinel Event Response

3. Peer Review Program

4. Peer Review Goals • Answer Specific Clinical Quality Questions • How well do we handle acute visits for otitis media? • Are we addressing substance abuse and mental health needs in the context of routine clinical visits? • Are we providing HIV counseling for patients on birth control? • Compare Quality Indicators to External / Internal Data • National or State benchmarks compare our care with other CHCs • Internal historical data evaluates changes over time

5. Peer Review Implementation • Providers Review Random Sampling of Each Other’s Charts • Peer Review Cycles Done Quarterly or Monthly • Definition of Peer • Standardized Audit Tool • For each chart, each question is compliant, deficient, or not applicable • General vs. Topic-Specific Audits • Selecting Audit Criteria www.guidelines.gov • Audit of Individual Visit, Past Year, Full Chart

6. How to Use Your Data • Analyze Individual Trends • Measure Individual Provider Performance Over Time • Compare Individual Results to Aggregate Data • Analyze Clinical Practice Trends • Are We Meeting Basic Quality Goals? • How Are We Doing Compared with Last Year? • Are We In Line With National Goals? • Educate Provider Staff • What Level Of Quality Can Realistically Be Achieved? • What Specific Areas Of Care Can I Improve?

7. Peer Review Data Response • Individual Patient Follow-Up • Provider Performance Review • Develop Provider-Specific Action Plan if Appropriate • Quality-Related Systems Changes • Develop Systems-Level Quality Improvement Activities if Appropriate

8. Chart Completeness Audits • Protects patient safety • Provides continuity of care • Measures accuracy, completeness, and legibility of medical records • Uses standardized tool

9. Sample Chart Completeness Questions • Is there an up to date problem list in the chart? • Is there an up to date medication list in the chart? • Are flow sheets current? • Are any lab reports up to date, initialed and dated? • Are all immunizations documented? • Does each form have the patient’s name on it? • Is there a signed consent to treat in the chart? • Are all entries signed? • Are drug allergies conspicuously documented?

10. Chart Completeness Audits • Evaluates chart documentation • Conducted daily, weekly, or monthly • Set goal for number of charts to review each audit • Can be done by non-clinical staff • Need immediate and systems-level response

11. High Risk Procedure Audits • Definition of high-risk procedure • Risk of serious complications • Examples include perforation & infection • Benefits of high-risk procedure audits • Identifies individual concerns • Identifies systemic concerns

12. High Risk Procedure Audits • Audit questions may include: • Was there excessive bleeding? • Was there an infection? • Was there perforation? • Was appropriate follow up conducted and documented?

13. Informed Consent for High Risk Procedure Audits • All Patients Should Sign Before High Risk Procedure • Understand Benefits & Risks • Be Informed Of Alternatives • Good Clinical Care • Liability Protection/ Risk Management

14. Patient Satisfaction • Why is Patient Satisfaction Important? • Customer Satisfaction • Measures Patient Care Quality • Demonstrates Commitment To Quality Care

15. Patient Satisfaction Survey • Culturally, linguistically, and reading-level appropriate • Typically annually • Results aggregated overall and by service / site • Present results to leadership and Board • Initiate PI projects to address most significant issues • Provide feedback to patients

16. Survey Topic Areas • Ensure representative sample • Maintain patient confidentiality • Topic Areas Include: • Appointments (Phone hold time; Same-day for urgent needs; Provider of Choice / PCP) • Staff (Courteous, helpful, and respectful; Ability to communicate well; Confidentiality and privacy) • Facilities (Clean and comfortable; Feeling of safety inside and outside; Clear signage) • Wait Time (Waiting room, exam room, check-out area; Information provided about wait time or if delays expected)

17. Other Patient Satisfaction Strategies • Patient suggestion/comment box • Staff training on de-escalation techniques • Ongoing consumer feedback – • “How are we doing?” cards • Patient focus groups • Board consumer member leadership • Patient complaint response and tracking systems

18. Patient Complaints

19. Patient Complaint Response Program • Document the complaint • Standardized complaint form • Who can complete form • When to complete form, “when in doubt, fill it out” • Where to place the completed form • Immediately rectify problem • Urgent medical need • Dirty rest room • Feedback to staff • Feedback to patient

20. Patient Complaint Response Program • Review handling of individual complaint • Handled with respect, efficiently, and effectively • Patient seems to feel better • Proper documentation • Appropriate follow-up • Identify complaint trends • Frequent types of complaints • Develop categories (may include: phone issues, staff misconduct, wait time, accessibility of services, failure to follow up, and translation or cultural issues) • Initiate PI project to respond to frequently occurring issues • Report trends to leadership and Board

21. Incident Response

22. Clinical Incident Categories Clinical Triage Clinical Evaluation Clinical Treatment Clinical Follow-Up Clinical Support Medication Lab Medical Emergency

23. Non-Clinical Incident Categories Communication Hazmat Spill Violent / Disruptive Patient Theft Accident / Injury Sexual Harassment Breach of Confidentiality

24. Incident Response is the Same as Complaint Response • Complete Incident Report Form • Include: Person completing form, people involved, date, time, location, description, response, resolution • Investigate What Happened • Interview involved staff and patients • Review medical records, phone message logs, appointment schedule • Feedback to all involved patients, visitors, staff • Immediate Response to Individual Incident

25. Incident Response is the Same as Complaint Response (cont) Identify Most Frequently Occurring Incidents (Trends) Report Trends to Leadership and Board Develop Systems-Level PI Response to Trends Staff training

26. Incident Tracking • Types of tracking systems • Paper or electronic tracking systems • Need to distinguish unresolved incidents • Variables to track and trend • Number of forms submitted overall • Most frequent categories • Changes over time

27. Sentinel Event Response

28. Sentinel Event Definition • Incident that caused death or serious injury (physical or emotional) • Near miss – incident that COULD have caused death or serious injury, even though this time it turned out OK • Does not include adverse outcome due to natural course of illness • Not the fault of an individual, multiple system failures

29. Examples of Sentinel Events • Rape or sexual exploitation on-site • Administering wrong medication • Not following up on abnormal lab • Dental extraction of wrong tooth • Mis-diagnosis, missed diagnosis, delayed diagnosis • Patient death immediately following a procedure

30. Incident Versus Sentinel Event • Sentinel event is a type of incident – SEVERE • Short-term response is the same as any incident • Utilize same report form and reporting procedures • Immediate response to individual incident • Not looking at trends, looking at individual event • Root cause analysis

31. Root Cause Analysis • Ask WHY X 5 • Team of 2 -3 people • Complete RCA quickly • Identify and correct systems failures • Plan for human error • Put backup systems in place

32. Case Study – Patient Suicide • Document, investigate, respond, and report the event • Identify root causes and system failures • Poor communication • Inconsistent scheduling • Unclear task assignments • Prevent recurrence

33. Final Thoughts on Improving Quality • Identify potential problems • Peer review • Chart completeness • Procedure audits / informed consent • Patient satisfaction program • Respond when things do go wrong • Patient complaints • Incidents • Sentinel Events • Implement in stages, full implementation within 1 year • Develop a comprehensive program

34. Resources • Bureau of Primary Health Care (BPHC) www.bphc.hrsa.gov • Your State’s Primary Care Association / Organization www.bphc.hrsa.gov/osnp/PCADirectory • Joint Commission on Accreditation of Healthcare Organizations (JCAHO) www.jcaho.org • Institute for Healthcare Improvement (IHI) www.ihi.org

35. Contact Us With Questions • National Association of Community Health Centers (NACHC) (301) 347-0400 contact@nachc.com www.nachc.com NACHC Managed Growth Assistance Program (Pamela Byrnes, Director) (860) 739-9224 pbyrnes@nachc.com • Trudy Brown Ripin or Molly Gwisc from Shoreline Health Solutions (860) 395-5630 info@shsconsulting.net www.shsconsulting.net