Rapid Cycle Improvement Model Applied To Chlamydial Screening in Teens

1. Rapid Cycle Improvement Model Applied To Chlamydial Screening in Teens A Partnership Between: Kaiser Permanente Northern California & University of California, San Francisco Mary-Ann Shafer, MD Division of Adolescent Medicine UCSF Supported by the Agency for Health Care Research and Quality & the Centers for Disease Control and Prevention

2. Objectives • Increase chlamydial (CT) screening of sexually active teen girls to meet HEDIS guidelines • Develop, implement and evaluate a systems-based intervention that capitalizes on existing clinic resources while addressing barriers to CT screening using a rapid cycle approach

3. BackgroundFacts About Chlamydia trachomatis (CT) • CT-mostcommonreportable STI in teens • Most asymptomatic-in males and females • NAATs- 90-95% sens & specfeasible • National Guidelines  annual CT screen (e.g. CDC, USPSTF, AAP, ACOG, AMA) • Only 25% of eligible population being screened

4. JAMA December 11, 2002

5. Learning Objectives • Review the development, implementation and evaluation of a systems-based rapid cycle clinical improvement intervention (CPI) to increase CT screening • Discuss the application of the CPI model to different clinical settings including identifying and overcoming barriers to success

6. Rapid Cycle Changes • Rapid Cycle Applied To CT Screen • Recruit team • Problem solve at • monthly meetings • Apply solutions & • assess each month • Repeat, sustain % Change in STD Screening Rate S t a t u s Q u o Time in months

7. Rapid Cycle Changes % Change in STD Screening Rate • Step 1: • Set Goal • Define measure • Identify barrier(s) • Decide solution • Try it out S t a t u s Q u o Time in months

8. Rapid Cycle Changes • Step 2 • Assess trial • Identify next barriers • Decide solution • Try it out % Change in STD Screening Rate S t a t u s Q u o Time in months

9. Rapid Cycle Changes • Step 3 • Assess trial • Identify barriers • Decide solution • Try it out • Repeat “cycles” • Sustain gains % Change in STD Screening Rate S t a t u s Q u o Time in months

10. Setting for Rapid Cycle Application • Setting • Large HMO in Northern California: KP • 10 pediatric clinics randomly assigned: 5-well care intervention and 5 control groups • 2 of 5 intervention clinics target both well and urgent care visits

11. Methods KP Pediatric Setting cont. • Well-Care Visit • Appointment required • Physical exam (every 2-3 yrs) • 20 minute visit • Urgent-Care Visit • Same/next day visit • Sick/non-ER visit • 10 minute visit • Same physical setting as WCV • Same providers & staff as WCV

12. Clinical Practice Improvement Model Engage Team Building Re-Design Clinical Practice Sustain the Gain

13. Clinical Practice Improvement Model • Leadership • Best practices • Define gap • Raise Awareness Engage Team Building Re-Design Clinical Practice Sustain the Gain

14. Clinical Practice Improvement Model • ACTeam • Skill building • Tool Kit Engage Team Building Re-Design Clinical Practice Sustain the Gain

15. Clinical Practice Improvement Model Engage • Customize • Measure success Team Building Re-Design Clinical Practice Sustain the Gain

16. Clinical Practice Improvement Model Engage • Monitor performance • Time series analysis • Continuous improvement Team Building Re-Design Clinical Practice Sustain the Gain

17. Site Specific Flow Chart Cue Charts Room Patient MD/NP VISIT Urines To Lab Follow-Up ID eligible teens • C Charts are stamped with cue MA collects FVU on all 14-18 yo F • TTeen takes FVU sample to exam room MD/NP obtains sex hx If sexually active, MD completes CT lab slip • W • WWrites confid. # on chart RN contacts CT + teen: confid. # Teen comes to clinic for Rx RN enters Rx in STD log book MA refrigerates FVUs A enters teen name, confidential # in clinic log book • LRunner takes FVU to lab

18. 1. Cue Charts • IIdentify eligible (target) population (14-18 y teens) • Charts stamped with cue (Y2P!) • C

19. 2. Room Patient • MMA collects FVU on all 14-18 yo • TTeen takes FVU sample to exam room • a • C

20. 3. VISIT • CMD/ NP obtains sexual hx • IIf sexually active, MD completes CT lab slip • WWrites confidential phone number on chart • C

21. 4. Urines to Lab • CMA refrigerates FVUs • MA enters teen name, confidential phone number in log book • LRunner takes FVU to lab • C

22. 5. Follow-up RN contacts CT + teen: confidential phone number Teen comes to clinic for Rx RN enters Rx into STD log book • C

23. Clinician’s Top Barriers to CT Screening in Primary & Urgent Care Settings • CONFIDENTIALITY: How separate parent? • TEEN SEX HX: How do I ask these things? • PRIORITIES: How competes in urgent care? • JOB DESCRIPTION: Is this part of my job? • PAYMENT: Who’s responsible? • POSITIVE CT RESULT: What do I do now?

24. Key Barriers Sample Solutions Confidentiality Universal urine collection Teen’s sexual history Teen-friendly rooming policy Site Teen Health Champion Anonymous chart reviews Priorities for limited time Re-think visit priorities Payment – copays Waived to protect teens small price to pay! Positives tests FU protocol in place

25. RESULTS Female CT Screening Rates*Pediatric Well-Care Visits (14-18 yo) *Chlamydia Screening Rate = #CT Tests/(#Well Care Visits *Sexual Activity Rate

26. RESULTS: Female CT Screening Rate in Urgent Care Pilot Sites % SA Females Screened for CT A A B A B B

27. Results of Intervention Evaluation • Dramatic improvement in well & urgent clinics • Sustainable & cost-effective • Clinic differences in approachrate of improvement varies • One solution does not fit all even within HMO

28. Implications • Rapid cycle quick, customized & sustained • Effective in different settings- well, urgent care & may be applied as a quality assurance tool • Capitalizes upon existing resources & staff • Smallchanges LARGE effects • Gives chronically over-worked staff sense of importance, success & control over workplace