NYS HIVQUAL Workshop: Improving Pap Scores February 20, 2009

1. NYS HIVQUAL Workshop: Improving Pap ScoresFebruary 20, 2009 Workshop Facilitators: Nanette Brey Magnani, EdD, Quality Consultant Dan Belanger, Director NYS HIV Quality Program AIDS Institute

2. Workshop Learning Outcomes • Understand the importance of Pap tests in cervical cancer screening for women with HIV • Understand your data • Apply PDSA cycle to pilot test ideas, on a small scale, to improve Pap rates at your program • Learn successful tips and strategies used by your peers and grantees across the country

3. Agenda 9:00 Introductions 9:15 Rationale and Purpose 9:30 Understanding Measures and Results 10:00 QI Projects and PDSA Cycles 11:30 Successful Strategies for Improvement 11:50 Next Steps and Evaluation 12:00 Adjourn!

4. 9:15 Rationale

5. What does screening do for cervical cancer rates? • Routine screening: 1965-1982 • Iceland 80% decrease • Finland 50% decrease • Sweden 40% decrease • US cases • 1973 14.2/100,000 • 1994 7.4/100,000 • Deaths • 1950 11.2/100,000 cases • 1987 6.1/100,000 • 1997 3.7/100,000 Gina M. Brown, MD Consultant to NYSDOH AI

6. National Screening Rates for HIV+ Women HRSA/HAB: National CADR (cohort of 785 providers) • Annual pap test completion mean rate – 40% (denominator = women with one medical visit in the calendar year) 2007 National HIVQUAL Data • Annual pap test completion mean rate – 68.2% (denominator = women with at least two medical visits in the review period, with at least one visit in each of the 6 month period) 2007 New York HIVQUAL Data • Annual pap test completion mean rate– 67.2% (DRAFT) (denominator = women with at least two medical visits in the review period, with at least one visit in each of the 6 month period)

7. What is our purpose?

8. 9:30 Understanding Performance Measurement

9. Performance Measures • HRSA measure • Number of female clients who had Pap screen results documented within the measurement year • Number of female clients who were 18 or older and were seen within the measurement year • HIVQUAL measure (current) • Number of female clients who had a Pap screen within the 12-month review period • Number of female clients who were seen twice within the 12-month review period with at least one medical visit in each 6- month period

10. Results Before taking action: • Is your data accurate? Why? • Do you understand your data? What else?

11. Example: Medical Center 2006 results: 15% CADR (HRSA) January 1, 2007 through December 31, 2007 HRSA 65 women with paps = 57% 113 women seen once HIVQUAL 39 women w/ paps = 67% 58 women seen at least once in each six month period January 1, 2008 through December 31, 2008 HRSA 63 women with paps = 47% 135 women seen once HIVQUAL 40 women w/ paps = 58% 69 women seen at least once in each six month period

12. From Data to Improvement:Linking Performance Data to QI Activities

13. QI Tools: Causal Analysis Tools: • Flow diagram • Fishbone diagram • Brainstorm

14. Medical Center Patient Specific Classification 41/63 = 65% for those we can impact at a primary level

15. Example: Histogram

16. Example: Clarify Current ProblemFlowchart Initial Process Through Sample Collection (Univ. of Pittsburgh Medical Center)

17. Example: Select the Process to Change-Fishbone Diagram (Univ. of Pittsburgh MC)

18. 10:00 QI Projects and PDSAs • QI Project = A Quality Improvement Project is generally comprised of several PDSAs within several categories of change • PDSA = Plan, Do, Study, Act

19. PDSA Cycle: Plan, Do, Study, Act

20. PDSA Measures A P Implementation of change S D D S P Wide-scale tests of change A A P S D Follow-up tests A P S D Very small scale test Repeated Use of Cycle Changes That Result in Improvement Learning from Data Hunches Theories Ideas

21. D S P A A P S D D S P A A P S D A P S D Example for PDSA Cycle Female clients receiving a pap test during any appointment if they need it DATA Cycle 1E: Implement and monitor result quarterly Cycle 1D: Incorporate suggestions, expand to third physician Cycle 1C: Continue with Dr. Z’s patients and expand to NP J’s patients for third week Cycle 1B: Try out the second week with Dr. Z’s patients incorporating suggestions from 1st week Cycle 1A: Try out with Dr. Z’s patients the first week

22. PDSA Cycle (cont.)

23. 10:30 Practice: Plan a PDSA • Use PDSA worksheet in folder • 10 minutes to work alone • 15 minutes to share with a partner • 1-2 minutes to share with group

24. 11:30 Improving Annual Pap Test/GYN rates Category Examples from National HIVQUAL Program Database:A. Raise awareness of need B. Patient education/incentivesC. System of care D. Scheduling and keeping appointmentsE. Most frequent interventions

25. A. Raise Awareness of Need • Highlight last Pap Test (Community Health Care, Davenport/Iowa..) • Print out pap rates by physician (UMass Medical Center…) • Tickler system to signal need • Notice in chart • Add to template (St. Mary’s Family Practice, GJ,CO)

26. A. Raise Awareness of Need cont’d • Daily chart review to identify need for scheduled patients (City of Portland/Positive Health…..) • Nurses set goals for % of Pap tests completed in a quarter (16th St.CHC, Milwaukee) • Include annual Pap test as a 5th vital sign, signal for alert (Brockton Neigh. Health Center….) • Pap bulletin board • CAREWare to track who needs annual GYN/Pap (Philadelphia Fight-Jonathan Lax Treatment Center)

27. B. Patient Education /Incentives • Targeted messages (Lynn CHC, MA, ARC/W, Gurabo CHC) • Targeted strategies on an individual basis • Send letter signed by providers as a reminder of appointment • Contacted directly by case manager • Pap and Pamper Bag (incl bath and body splash from Bed and Bath; $20 gift card to Target – INOVA)

28. B. Patient Education/Incentives cont’d • $20 gift card for women who are chronic no shows for Pap appointments (Family First, York,PA) • General incentives (Lehigh Valley Hosp, Allentown, PA) • Annual GYN exam/Pap scheduled at time of patient’s birthday (Univ of Illinois/College of Medicine, Peoria) • Explain data for abnormal Pap smears (Lancaster Gen. Hosp/PA)

29. C. System of Care Changes • Perform Pap test if needed during any appt. (Unity Health Care, 16th St.CHC, Heartland Health Outreach, ARC/W, City of Portland/ Positive Health, Southside Health Association/Chicago, Jordan Hospital/Access Program, Fletcher Allen/VT, East Boston NHC) • Add to intake (Catholic Charities Diocese of Fort Worth,TX) • Refer to female practitioner, ob/gyn (St. Joseph Medical Center, Reading, PA; Concilio de Salud Integral de Loiza/PR) • Integrate into annual physical exam (Lynn CHC, MA)

30. C. System of Care Changes cont’d • Team approach to discussing multi-pronged approach (Gurabo CHC/PR…) • Offer gyn exams at clinic (new offering, Puerto Rico CoNCRA) • Improve documentation from external providers (Southside Health Association, Chicago;Jordan Hosp/Access Project/MA,Lancaster Gen.Hosp/PA) • Women’s health initiative (St. Mary’s Family Practice, Grand Junction, Un of Pittsburgh Medical Center) • Train NPs to do Pap Tests (Detroit Medical Center) • Exam room decorated like a spa (INOVA)

31. D. Scheduling and Keeping Appointments Schedule Pap appt. within 3 weeks of identifying need Schedule if needed Schedule at time of birthday as an annual reminder to both female clients and staff Same day appointment (El Proyecto Del Barrio) Reminder calls by HIV nurse, staff, or bilingual outreach worker (Brockton NHC, Southside Health Association) Letters from physicians and NPs Reminder letters/cards (Partnership Health Center, Scranton Temple Residency Program) No show letters

32. Most Frequent Interventions From 31 Different Interventions: • Perform pap if needed during any scheduled appointment - 19 • Reminder letters and calls – 10 • Patient education - 5

33. Oops…..Not so fast

34. Example: GYN QI Project Results

35. How To Sustain the Gain • Share examples • Brainstorm additional ideas

36. Monitor to Sustain the Gain • Run Chart prepared by Medical Director for Solano County Family Health Services for a presentation to County Board of Supervisors and the County Public Health Department’s QI Committee • 2 sites: Fairfield and Vallejo • Improvement strategies included • Better reminder system • Added female Nurse Practitioner

37. Solano County Family Health Services

38. THANK YOU FOR YOUR PARTICIPATION TODAY!!!

39. Upcoming Workshopswww.HIVQUAL.org March 20th - Thinking Outside the Box: Creativity and QI Presenters: Dan Sendzik + Meera Vohra Location: NYSDOH AI,90 Church Street, 4th Floor Room A/B, NYC April 17th-Writing and Updating a QM Plan Presenters: Nanette Brey Magnani + Susan Weigl Location: Hispanic Federation, 55 Exchange Place, 5th Floor, NYC May 15th- Staff ownership and Consumer Involvement Presenters: Dan Belanger+ Daniel Teitz Location: NYSDOH AI,90 Church Street, 4th Floor Room A/B, NYC