Applying Quality Improvement Principles in the Community Health Care Setting

1. Applying Quality Improvement Principles in the Community Health Care Setting Presented by: Amanda McIntyre RN, BScN, MN/PHCNP(C) Candidate Danielle Kenyon PHC-NP, MN

2. Who We Are & What We Do • Model of Care: Community Health Centre (CHC) • 3 locations: east end, central & west end • Population served: vulnerable immigrants, refugees & non-status persons • Multidisciplinary team: MDs, NPs, RN/RPNs, MSWs, RDs • Community Programs

3. Agenda Health Equity: Where does QI fit in? 1 PDSA cycle: Introducing the Plan-Do-Study-Act Cycle (PDSA) 2 3 Activity: Create your own PDSA cycle! 3 Process Mapping: Improving access for Government Assisted Refugees (GARs) 4

4. What is Health Equity? • Equal access to health care for all • CHCs address health inequities by focusing efforts on vulnerable groups • Quality improvement used to improve efficiency of care

5. Defining Quality Improvement (QI) “Quality improvement in public health is the use of a deliberate and defined improvement process, such as Plan-Do-Check-Act, which is focused on activities that are responsive to community needs and improving population health. It refers to a continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality in services or processes which achieve equity and improve the health of the community.” (R. Bialek, L. M. Beitsch, A. Cofsky, et al, unpublished data, 2009). Riley, W.J., Moran, J.W., Corso, L.C., Beitsch, L.M., Bialek, R., & Cofsky, A. (2010) Defining Quality Improvement in Public Health. Journal of Public Health Management & Practice, 16(1), 5–7. doi: 10.1097/PHH.0b013e3181bedb49

6. Office Practice Redesign • A process used to improve office efficiency • The process involves: • Identifying areas for improvement • Collecting data to support the need for improvement • Planning and testing a change • Analyzing data throughout the test process • Implementing change or testing a new change idea • Benefits: • Results in an efficient use of resources • Improved patient outcomes and increased satisfaction • Reduces/eliminates waste and/or delays

8. Keys to Good Data Collection • Explicitly state the questions to be answered by the data • Measurement • Consider using sampling • Design and test a form for collecting the data • Train those who will collect the data

9. Contraception PDSA

10. Contraception PDSA • March 2011: reviewed contraception policies & practices • Problems identified: • Monetary losses • Not well tracked or monitored • Orders placed twice/year • Pricing strategy outdated • New providers = ? different prescribing practices

11. Contraception PDSA • Next steps: • Surveyed providers & adjusted ordering to reflect prescribing practices • Adjusted pricing strategy to reflect cost to agency • No more 21 day packs! • Increased frequency of ordering (4x/year) • Spreadsheet: track contraception in & out • Developed a new CHIT and process for providers

12. The Spreadsheet

13. The CHIT

14. The Dollars and Cents

15. Wastage • April 2011 - December 2011: $6, 936.05. • January 2012 – December 2012: $980.45. • January 2013 – December 2013: $2, 057.30

16. What Comes Next? • Next steps: • Continue to monitor the spreadsheet & ensure inventory in reflects inventory out • Adjust our pricing strategy as needed to reflect cost changes from drug companies • Ongoing: check in with any new providers that come on board re: prescribing practices

17. Contraception PDSA • What is the objective for this cycle? • Within 6 months: • Inventory will be tracked, and ordering practices will be changed. • Contraception prescribing practices will be determined and monitored. • Reduce financial loss to 50%.(loss includes compassionate assistance)

18. Contraception PDSA What questions do you want to answer with this PDSA cycle? • What are the most commonly ordered contraceptives? • How much of our cost are we recouping? • How much inventory should we stock of each brand on a quarterly basis? • What is the most effective method to track our inventory?

19. Contraception PDSA Predictions (for questions above based on plan): • Most commonly used contraceptives are likely: Alesse, Tricyclen-lo, Micronor, and DepoProvera. • Recouping 50% of our cost. The other 50% is lost through compassionate assistance, expired product etc. • We are unable to predict required quarterly inventory at this time as no data to review. • The contraception inventory/dispensing spreadsheet will be effective IF used correctly by all participating providers. E.g. if a policy is in place and everyone follows it.

20. Contraception PDSA List tasks required to set-up this test: Who, What, When, Where?

21. Contraception PDSA Plan to collect data to answer your questions: Who, What, When, Where?

22. Contraception PDSA

23. Contraception PDSA

24. PDSA Case Study • Problem: low rates of smoking cessation program utilization • Goal: To increase smoking cessation program uptake • Your task: think of a strategy to test (to increase program uptake) and complete Plan section of PDSA

25. Plan • What is the objective for this cycle? • Keep this in mind: • Is your aim/objective SMART? • Specific • Measurable • Achievable • Realistic • Timed

26. Plan • What questions do you want to answer with this PDSA cycle?

27. Plan • Predictions (for questions above based on plan):

28. Plan • List tasks required to set-up this test: Who, What, When, Where?

29. Plan • Plan to collect data to answer your questions: Who, What, When, Where?

30. Do • What did you observe when the test was carried out? Were there any unexpected observations? Study • Analyze your data and describe the results. How do the results compare with your predictions? • What did you learn from this cycle?

31. Act • Are you ready to implement? (Feel confident in the change, have tested it under different conditions and have no more questions)  yes  no • Plan for the next cycle (Have more questions, need to make adjustments). • Describe the objective for your next cycle:

32. Improving Access to Healthcare for GARs

33. The COSTI Clinic for GARs • Long-standing partnership between Access Alliance & COSTI reception centre • Provides episodic care to GARs during their ~2 week stay at COSTI reception centre • Identifies GARs with higher needs/chronic health issues who need to be linked with a PCP more urgently (taken on as clients at Access Alliance)

34. Process Mapping • Simple visual picture, or map, of a process • Used to better understand how parts of the process function • Intended to make improvements to the process

35. Eat in or out? Eat out Eat in Pick a recipe Choose restaurant Get the ingredients Make a reservation Get to restaurant Prepare & cook food Eat food Wash dishes Pay & leave

36. First Contact Clinic 1-2/week, onsite @ COSTI reception center - triaged High-needs client identified, based on CIC determination or chronic issue identified by COSTI/AA PCP Faxed Referral Triaged by AA staff, apt booked Acute/Episodic health issue identified Client is rostered to PCP at College Initial Visit Care through College on non-COSTI clinic days, caseworker faxes referral, episodic, give next available appt, no initial visit. If status changes to high needs, PCP flags to on board & ptrostered. Chart open, not rostered, identifier used, gives encounters, 1 year access @ College, flagged F/U appointment AA Orientation Ongoing care as needed at College Transfer to another site prn if client has special needs – geo location, access/ability, etc. Transfer note completed Appt at other AA location, rostered to new PCP at first appointment

37. Creating a Culture of Change • Sharing your successes • Spread the language of QI • Get people excited about change! • Impact on the agency as a whole • Next steps: consideration of spreading QI into other areas of the agency

38. Questions? • Contact info: • Amanda McIntyre – amcintyre@accessalliance.ca • Danielle Kenyon – dkenyon@accessalliance.ca