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Using Peer Chart Audits for Qualitative Improvement

Explore the history, key components, and implementation steps of peer chart audits to enhance clinical practice standards and improve patient care outcomes. Learn about conducting peer reviews, QI components, and pros/cons of this valuable process.

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Using Peer Chart Audits for Qualitative Improvement

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  1. Using Peer Chart Audits for Qualitative Improvement WE-2.03 Diana Denning, mph, msn,whnP-BC Administrative Director, Brandeis University Margaret Fitzgerald, MSn,FNP-BC Associate Director Bentley University 10/23/2019

  2. Brief Overview of Session Definition and Key Components Implementation steps and experiences Planning your next steps

  3. Peer Review is the mechanism to: Evaluate the quality and quantity of care based on practice standards. Determine the strengths and weaknesses of care based on practice standards. Provide evidence for change in practice protocols to improve care Identify practice patterns that indicate a need for more knowledge.

  4. Key Components Peer Chart Reviews Clinicians develop and apply criteria, set goals, participate in collection and analysis of data that is used to evaluate outcomes of care that was provided. Can be a part of an organization’s quality improvement initiative. It is a requirement of accredited organizations. How it is conducted can vary across institutions.

  5. History of Peer Review 1952 JCAHO required physician peer review in all US hospitals.  1986, the Health Care Quality Improvement Act (HCQIA) was enacted by Congress.  (WJG, Vyas and Hozain, 2014). 1988, ANA publishes Peer Review Guidelines.

  6. ANA Peer Review Guidelines Is conducted by someone of the same rank or performs the same duties. Is practice focused.  Provides feedback that is timely, routine and is continuously expected. Fosters a continuous learning culture of patient safety and best practice.  Feedback is not anonymous.  Feedback incorporates the developmental stage of the clinical provider (Foster, 2015). Is not considered optional.

  7. Peer Review is a component of QI Quality Improvement (QI) Key components QI : Systematic and continuous actions that lead to a measurable improvement in health care services and the health status of targeted groups. QI is systems: inputs+ processes=outcomes Focuses on patients Focuses on building team Focuses on use of data

  8. Using Peer Review to create a QI study Steps to take: 1. What is the known or suspected problem? 2. What is our measurable performance goal? 3. How will the data be collected? 4. What is the evidence of that data collection? 5. What is the data analysis? 6. How does it compare to your performance goal? 7. What actions were implemented to resolve identified problems?

  9. Pros and Cons of Peer Chart Reviews Pros Cons Standardization of site practice Increased staff engagement and education Increased quality of care  Measure and demonstrate the effectiveness of what we do. Improves safety and decreases risk Promotes commitment to improvement Time and Staff Resources: For defining and writing up procedures For tool development/ selection For analysis/review For staff participation For reporting 

  10. Our Universities Bentley University Brandeis University Waltham, MA -12 miles west of Boston. 4,300 Ugrads 1,300 Grads Accredited by AAAHC in August, 2018 Health Center has MD Assoc. Dean/Dir, NP Assoc.Dir,  4.0 NP,0.4 FTE MD , FT RN Waltham, MA -12 m. west of Boston.  3,600  Ugrads 2,100 Grad Health Center staffing : Admin: 0.5 MD Medical Director ,  0.9 FTE NP Adm. Director  3.4 FTE NP, MD (+2 per diem NP's),PT RN, FT MA

  11. Implementation Considerations • Your approach should be to provide a safe, learning environment for staff • The process should be fair, reliable and nonpunitive. • Written and standardized operating procedures for peer review also need to be developed and adopted by the direct care staff and incorporated into the professional practice model (shared governance) bylaws.

  12. Step 1:  Criteria/Goal Selection • Ask why are we doing this?  Should be meaningful to your practice. • Could be areas in practice, treatment, outcomes.  • Are diagnoses being managed differently? Do you want to improve vaccination rates? Do you want to support following a new clinical guideline? • Could be process oriented-communications regarding labs, follow up  etc. • Inspiration can come from issues raised in  staff meeting, new guidelines published, case reviews, patient satisfaction survey feedback.

  13. Step 2: Determine External Criteria (benchmark) • Determine what guidelines/generalizable scientific  evidence being used as external reference • Examples :  • Skin infections (IDSA) • Centor Criteria (ACHA-pharyngitis tool) • Coding guidelines (CMS guidelines for E/M) • Ottowa Ankle rules (ACHA Ankle tool)  • USPTF recommendations , Cochrane reviews, 

  14. Step 3: Development of Tool  • What is being measured?  Needs clear definition. •  Pull visits by Dx codes?  Visit types?  Timeframe defined • How is it being measured?  • Keep it Concrete, measurable, defined. Yes /no questions etc.  • HIPPA data deidentification • Identify performance goals should you want to make it into a quality improvement study

  15. ACHA Tools  ACHA has  4 tools available- you will need to articulate how you pull charts, how data is compiled/shared, create the outcome report, and follow up plans. https://www.acha.org/ACHA/Resources/Clinical_Benchmarking.aspx Pros: well defined criteria, directions, worksheets, can be  added to national database with another data entry  Cons: need to collect data and data enter, set up own analysis, need two screens to data review/enter or data enter paper reviews.  

  16.  BENTLEY Use of Google Survey Tool Step 1: Go to forms.google.com. Click Blank, format your form. Step 2: Send your form (send a link) for people to fill out. Step 3: Analysis of data through google or export to excel. 

  17. Integrating Google Survey and SAS The google survey data (in an excel document) can be uploaded into SAS (statistical analysis software) to run descriptive statistics.   Pros: Ease of data collection and analysis, can do analysis by provider which can be very motivating. Con: Cost, expertise, access with SAS

  18. Brandeis Peer Review Outcomes • Used ACHA tools  • Ottowa screening and outcomes: We  added a screening tool to our EHR for consistent documentation,  we also did a peer training in x ray ordering and reviewing • Bronchitis- We found our practice was consistent and met goals for appropriate antibiotic use • Pharyngitis-We found some providers did WAY more testing regardless of centor criteria, elicited dialogues around patient demand and managing that. f/u planned for this year!

  19. Some of Our Own Reviews Review of documented responses to SBIRT questions in 2016 and 2017- Found discrepancies, missed responses. This was motivating to providers and a repeat chart review  showed improvments.  Pap follow up tracking – We are consistent and met goals for patient notification. Coding review done in 2018-19-We found that we were vastly undercoding.  NP's reported increased comfort with  coding standards, and appropriate coding. LTBI –Our next project: Goal: Increase completion of treatment for students we diagnose with LTBI.

  20. Peer Review/QI at Bentley Used AAAHC's clinical records worksheet to devise areas to look at in terms of our clinical note.  We set performance goals of 75% initially and once achieved moved to 90%. A Skin Infection study in which we benchmarked using the IDSA (Infectious Disease Society of America) guidelines for skin infections and set a goal for providers to meet indicators at least 75% of the time 

  21. More google survey examples Depression Screening using the PHQ 3 and then 9 if indicated and whether appropriate referral and follow-up was done on students who had a PHQ >10. Concussions- followed CDC guidelines and clinical recommendations. Tonsillitis-used Centor criteria to evaluate appropriate antibiotic use for sore throats. UTI's-looking at clinician antibiotic choice after first line recommendations were made.

  22. Other examples of Peer Review done at Bentley Sinusitis-standardize our care and align it with the most current guidelines from the American Academy of Otolaryngology. 

  23. Step 4: Outcomes/evaluation How measured ? Again, what were your internal benchmarks? How is it linked to identifying systemic change needs/plans?  How reported and to whom Not used for performance evaluation  SAS (statistical analysis software) option (https://www.youtube.com/watch?v=JPATJfQNSlQ) vs google option

  24. PEER Review Outcome Reports Bentley Brandeis Reported to all staff and department Reported in quarterly trustee reports and annual report. Reported to AAAHC. Mostly for internal Health Center improvement Basic outcomes included in  routine reporting to University and  Student Health Advisory Committee

  25. Start your own Peer Chart Audit Plan Select an area of interest for review How will you bring it to your team? What might be the agreed upon goal of this review? What professional standards or practice guidelines  can you use for external  benchmarking? What tools for data collection and reporting might you use? What  challenges to implementation /reporting do you have? What are some ways of meeting these challenges?

  26. Questions/ feedback

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