Sponsored by the National Association of Community Health Centers Presented By Shoreline Health Solutions, LLC Trudy

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