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 Performance Improvement in Community Health Centers

2. Presentation Goals • Understand Performance Improvement methodology, as well as practical techniques for quality improvement. • Effectively use the PI model in a new start Community Health Center • Review case studies to demonstrate PI in real scenarios • Understand proactive and reactive performance improvement strategies

3. Improving Performance • How do we know we are providing high quality care and services? • Do we set and achieve appropriate and realistic goals? • How do we measure improvement?

4. What is Performance Improvement? • Performance Improvement (PI) is a continuous, systematic process for improving the agency’s care, service and operations.

5. Why do Performance Improvement? • Methodological way to ensure high quality care & patient safety • Tells you if changes worked • PI model gives you concrete steps to simplify a complex process • BPHC and JCAHO require it

6. What If We Don’t Measure? • You won’t know if the change WORKED • You won’t know WHICH PART of the change worked • You could make things WORSE • Others may NOT BELIEVE the change worked

7. Selecting a PI Project • Triggered by a specific incident • Based on existing data trends • Prioritizing: High Risk, High Volume, Problem Prone • Directly impacts patient care or patient satisfaction

8. Key Elements of a PI Model • Establish baseline • Set benchmark • Make change • Measure your change • Follow-up

9. FOCUS - PDSA • PDSA is one of many models for PI • Four - step cycle to plan and measure change • FOCUS component maps out Pre-Work to PDSA

10. FOCUS Find a process to improve Organize a team Clarify what is currently happening (baseline data) Understand where and why problems occur Select the process improvement and benchmark

11. PDSA Plan the Performance Improvement strategy Do a trial run, collect data as you go Study your results Was there a measurable improvement? If not, go back to PLAN until benchmark is achieved Act! Ongoing monitoring for sustained improvement

12. Operational PI Examples • Patient Wait Time • Patient Satisfaction • Staff Satisfaction • Claims Denial • Collections

13. Operational PI Case Study Improving Patient Wait Times F Chose wait times in response to patient demand - patient complaints O Formulated team involved in areas of wait time – included a clinical provider, medical assistant, registration staff, billing staff, senior management C Collected baseline data through wait time study U Understood problem areas by clarifying where delays occur - delays occurred at registration, waiting in exam room, and billing S Selected to de-centralize intake as first process improvement – benchmark is reducing wait time by 20 minutes.

14. Operational PI Case Study Improving Patient Wait Times P Plan thoroughly developed and outlined by team D Plan implemented in pediatrics S Data collected and not at benchmark – repeat cycle A Benchmark achieved!! Implemented changes in all departments

15. High Level Integration • An effective PI program incorporates all data sources through a central PI Committee and integrated PI Program infrastructure.

16. PI Committee Structure • Select Representative Members • Integrate into all sites • Meet regularly • Appoint PI Coordinator • Complete assignments between meetings • Select 1-2 PI Priorities Annually • Appoint PI Teams • Ensure Ongoing Monitoring • Review Key Data Trends From All Sources

17. Components of PI Program Proactive Strategies • Peer Review • Chart Completeness Review • Informed Consent – High Risk Procedures • Patient Satisfaction Reactive Strategies • Incident Tracking • Patient Complaint Tracking • Sentinel Event Response

18. Peer Review • Providers Review Each Other’s Charts • Standardized Audit Tool • Identify Trends • Report Results to Staff and Leadership

19. Peer Review Goals • Review Individual Trends Over Time • Review Clinical Practice Trends • Answer Specific Clinical Questions

20. Chart Completeness Review • Evaluates Medical Record Documentation • Checklist is Standardized • Usually Done Monthly • Can Be Done By Non-Clinical Staff

21. High Risk Procedures – Informed Consent • What is a High-risk Procedure? • Risk Of Serious Complications • Examples Include Perforation & Infection • Informed Consent Needed • Understand Benefits & Risks • Be Informed Of Alternatives • Good Clinical Care • Liability Protection/ Risk Management

22. Patient Satisfaction Program • Components of a Comprehensive Pt Satisfaction Program • Surveys • Staff Training • Patient Suggestion/Comment Box • Patient Complaint Tracking System

23. Incident Tracking • Documenting the Event • Incident Review • Resolving the Incident • Identifying Trends

24. Patient Complaint Tracking • Identifies customer service and communication problems • Utilizes same process as Incident Tracking • Rapid response to each complaint • Feedback to patient describing agency response • Complaint patterns indicate systemic problems • Structured response to systems problems

25. Sentinel Event Response • What is a sentinel event? • Near Miss • Do Not Wait for a Trend • Root Cause Analysis

26. Clinical PI Examples • Triage: • Child with 104 degree fever scheduled for next day appointment • Walk-in patient left waiting for 2 hours when should have been sent to ER • Evaluation • Missed Diagnosis • Mis-Diagnosis • Labs not ordered • Treatment • Wrong medication prescribed • Perforation during IUD insertion

27. Clinical PI Examples • Lab Issues • Patient given wrong person’s test results • Lab tests ordered, but never done • Results never come back from outside lab • Controlled Substances • Stolen prescription pads / forged prescriptions • Patient seeing multiple providers / pharmacies to obtain controlled substances

28. Clinical PI Examples • Chart Documentation • Illegible handwriting • Provider seeing patient without chart • Phone/ Communication • Provider never receives patient message • Language and cultural barriers

29. Clinical PI Case Study Follow-Up for Abnormal Labs F Identified problem through incident tracking. O Team included Medical Director, Nurse Coordinator, Medical Assistant, Lab Tech, staff person receiving mail / fax / delivery of lab results. C Baseline data collected via lab testing log, 3 week period reviewed. U Problem areas included use of multiple outside labs, high volume, part-time clinicians, no clear person in charge of process. S Identified responsible person to track all abnormal labs. Benchmark set at 100% follow-up rate within 24 hours of notification.

30. Clinical PI Case Study Follow-Up for Abnormal Labs P Plan thoroughly developed and outlined by team. D Implemented for three providers S Data collected: 24-hour follow-up achieved for 95% of cases. Not at benchmark – repeat cycle. A Benchmark achieved!! Implemented changes for all providers.

31. Resources • NACHC www.nachc.org • BPHC www.bphc.hrsa.gov • JCAHO www.jcaho.org • Institute for Healthcare Improvement www.ihi.org • Your State’s Primary Care Association/Organization • Contact us with questions (Trudy or Molly, Shoreline Health Solutions) info@shsconsulting.net or (860) 395-5630