Maricopa Integrated Health System

1. Using the PDSA Cycle to Successfully Implement an HIV Rapid Testing Program in Hospital Labor & Deliveryby Debra WelbornMaricopa Integrated Health System Funding by the Department of Health and Human Services, Health Resources and Service Administration, the Ryan White CARE Act Amendments of 2000 and the Maricopa Integrated Health System

2. Maricopa Integrated Health System • Maricopa Integrated Health System (MIHS) is is a special health care district in Phoenix, AZ • MIHS includes: • Acute care hospital, Maricopa Medical Center, with 449 beds • 12 ambulatory health centers including an HIV (Ryan White) health center, • Psychiatric services, Arizona burn center, Level 1 trauma center. • MIHS is the grantee in Maricopa County, Arizona for: • Title III since 1991- 1563 clients, • Title IV since 1998- 988 clients • Title I since 1994 and Title II since 2005

3. Maricopa Integrated Health System • Maricopa Medical Center (MMC) is #3 in Maricopa County for the largest number of deliveries for uninsured, indigent and refugee women. • As a Title IV initiative, MMC went “live” on July 1, 2005 with its program: ‘HIV Rapid Testing in Labor & Delivery’. Criteria: • Ensure that Rapid HIV test is offered to 100% of moms (in imminent labor) who do not already have a documented HIV test or who are at high-risk of contracting HIV during the pregnancy • Ensure effective pre-test & post-test counseling with appropriate referrals

4. Challenges in Using Data • Trouble collecting data: • The only way to identify women with no prenatal care is with the manual labor log. Electronic reports are unavailable. • The only way to identify women with high risk factors is through a chart review of 100% of deliveries. • The only way to compute compliance rates is not with a lab monitoring log, but through chart reviews of electronic medical records. • Problems sharing data: • Data is shared through the Perinatal PI Committee with the department heads. The information, however, is not always communicated to other practitioners.

5. Challenges in Using Data • Difficulties with analyzing data: • Chart Reviews are time consuming: Except for lab results, information is ‘hidden’ in the margins of progress notes, nurses notes or labor & delivery notes. • Follow-up problems: • Minimal, but includes staffing changes, priorities and limited resources remain. • Sustainability issues: • Human resources for data collection and analysis are limited.

6. Solutions • MIHS Implemented a CQI Study methodology as illustrated in the Venn Diagram: Adoption and continuous review of national standards Lab Monitoring Chart Review- Process changes Physician Satisfaction Survey

7. Improvement Projects PLAN: Review national data and guidelines; Attend CDC conference; Meet with hospital who had implemented a program 9 months prior to MIHS; Create project team to implement program; Train nurses, social workers, physicians, residents, lab personnel and others on new program; Obtain approval from hospital compliance officer & verify HIPAA compliance. DO: Adopt local protocols, guidelines and procedures “GO LIVE” on July 1, 2005; Implement QI Plan and study methodologies; Create brochures & give presentations to local staff as well as to other hospitals. PDSA cycles were crucial to the success of the program:

8. Improvement Projects Study: Monthly lab monitoring: actual # of tests. Quarterly medical record reviews:compliance rates. Annual physician satisfaction survey. ACT: Co-sponsor OB High-risk Conference with CDC speaker- Dr. Branson. Continue training staff, physicians and residents. Present data at quarterly Perinatal PI meetings Send individual cases to Peer Review Change processes as appropriate- e.g. change lab procedures, eliminate ELISA tests Implement Phase II at hospital: Re-testing moms who have new risk factors. PDSA cycles were crucial to the success of the program:

9. Lessons Learned • You can start a new program and implement a PDSA cycle without total physician buy-in, but it’s problematic. Adjustments are required and improvements are gradual. • Consultation/training from known “experts” are essential to the CQI process- they provide credibility as well as motivation for local practitioners.

10. Improvement Projects MMC Births:Approximately 300+/month HIV Test Results: One (1) False Positive Test -July 2005. (Western Blot was negative) No (0) True HIV Positive Tests

11. HIV Rapid Testing in L & D- Process and Outcome Measurements for FY05-06 Goal Results- August 05 n=317 Results- 4th Quarter 05 n=99 Results- 1st Quarter 06 n=130 Results 2nd Quarter 06 n=120+ >50% 45% 25% 56% >70% >90% 93% 90% 98% >95% Number of Rapid tests performed/total number of women in imminent labor who have had no prenatal care (‘defined as 0-1 prenatal care visits’) (% Compliance Rate)- L & D Only Number of women who have had at least 1 HIV test during current prenatal care/total number of women who delivered at MMC & excludes those that declined (% Compliance Rate) (FHCs & physician offices) Improvement Projects

12. Stay Tuned for Part II • MIHS’ initiative includes providing technical assistance to all other hospitals with L & D departments in Maricopa County who have not yet implemented an HIV Rapid Testing Program. • MIHS & AETCs are looking at ways to partner on HIV Rapid Testing programs. • For further information contact: Debra Welborn, Title IV Program Coordinator at 602-344-2628. See also www.mihs/org/ryanwhite