Implementing Quality Improvement Activities at Your Community Health Center 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

Components of PI Program Proactive / preventative strategies Before something goes wrong Peer Review Chart Completeness High Risk Procedures Patient Satisfaction Reactive / responsive strategies After something goes wrong Patient Complaint Response Incident Follow-Up Sentinel Event Response

Peer Review Program

Peer Review Goals Answer Specific Clinical Quality Questions How well do we handle acute visits for otitis media? Are we addressing substance abuse and mental health needs in the context of routine clinical visits? Are we providing HIV counseling for patients on birth control? Compare Quality Indicators to External / Internal Data National or State benchmarks compare our care with other CHCs Internal historical data evaluates changes over time 4

Peer Review Implementation Providers Review Random Sampling of Each Other’s Charts Peer Review Cycles Done Quarterly or Monthly Definition of Peer Standardized Audit Tool For each chart, each question is compliant, deficient, or not applicable General vs. Topic-Specific Audits Selecting Audit Criteria www.guidelines.gov Audit of Individual Visit, Past Year, Full Chart

How to Use Your Data Analyze Individual Trends Measure Individual Provider Performance Over Time Compare Individual Results to Aggregate Data Analyze Clinical Practice Trends Are We Meeting Basic Quality Goals? How Are We Doing Compared with Last Year? Are We In Line With National Goals? Educate Provider Staff What Level Of Quality Can Realistically Be Achieved? What Specific Areas Of Care Can I Improve? 6

Peer Review Data Response Individual Patient Follow-Up Provider Performance Review Develop Provider-Specific Action Plan if Appropriate Quality-Related Systems Changes Develop Systems-Level Quality Improvement Activities if Appropriate 7

Chart Completeness Audits Protects patient safety Provides continuity of care Measures accuracy, completeness, and legibility of medical records Uses standardized tool 8

Sample Chart Completeness Questions Is there an up to date problem list in the chart? Is there an up to date medication list in the chart? Are flow sheets current? Are any lab reports up to date, initialed and dated? Are all immunizations documented? Does each form have the patient’s name on it? Is there a signed consent to treat in the chart? Are all entries signed? Are drug allergies conspicuously documented?

Chart Completeness Audits Evaluates chart documentation Conducted daily, weekly, or monthly Set goal for number of charts to review each audit Can be done by non-clinical staff Need immediate and systems-level response

High Risk Procedure Audits Definition of high-risk procedure Risk of serious complications Examples include perforation & infection Benefits of high-risk procedure audits Identifies individual concerns Identifies systemic concerns

High Risk Procedure Audits Audit questions may include: Was there excessive bleeding? Was there an infection? Was there perforation? Was appropriate follow up conducted and documented? 12

Informed Consent for High Risk Procedure Audits All Patients Should Sign Before High Risk Procedure Understand Benefits & Risks Be Informed Of Alternatives Good Clinical Care Liability Protection/ Risk Management

Patient Satisfaction Why is Patient Satisfaction Important? Customer Satisfaction Measures Patient Care Quality Demonstrates Commitment To Quality Care 14

Patient Satisfaction Survey Culturally, linguistically, and reading-level appropriate Typically annually Results aggregated overall and by service / site Present results to leadership and Board Initiate PI projects to address most significant issues Provide feedback to patients

Survey Topic Areas Ensure representative sample Maintain patient confidentiality Topic Areas Include: Appointments (Phone hold time; Same-day for urgent needs; Provider of Choice / PCP) Staff (Courteous, helpful, and respectful; Ability to communicate well; Confidentiality and privacy) Facilities (Clean and comfortable; Feeling of safety inside and outside; Clear signage) Wait Time (Waiting room, exam room, check-out area; Information provided about wait time or if delays expected) 16

Other Patient Satisfaction Strategies Patient suggestion/comment box Staff training on de-escalation techniques Ongoing consumer feedback – “How are we doing?” cards Patient focus groups Board consumer member leadership Patient complaint response and tracking systems 17

Patient Complaints 18

Patient Complaint Response Program Document the complaint Standardized complaint form Who can complete form When to complete form, “when in doubt, fill it out” Where to place the completed form Immediately rectify problem Urgent medical need Dirty rest room Feedback to staff Feedback to patient

Patient Complaint Response Program Review handling of individual complaint Handled with respect, efficiently, and effectively Patient seems to feel better Proper documentation Appropriate follow-up Identify complaint trends Frequent types of complaints Develop categories (may include: phone issues, staff misconduct, wait time, accessibility of services, failure to follow up, and translation or cultural issues) Initiate PI project to respond to frequently occurring issues Report trends to leadership and Board 20

Incident Response 21

Clinical Incident Categories Clinical Triage Clinical Evaluation Clinical Treatment Clinical Follow-Up Clinical Support Medication Lab Medical Emergency 22

Non-Clinical Incident Categories Communication Hazmat Spill Violent / Disruptive Patient Theft Accident / Injury Sexual Harassment Breach of Confidentiality 23

Incident Response is the Same as Complaint Response Complete Incident Report Form Include: Person completing form, people involved, date, time, location, description, response, resolution Investigate What Happened Interview involved staff and patients Review medical records, phone message logs, appointment schedule Feedback to all involved patients, visitors, staff Immediate Response to Individual Incident 24

Incident Response is the Same as Complaint Response (cont) Identify Most Frequently Occurring Incidents (Trends) Report Trends to Leadership and Board Develop Systems-Level PI Response to Trends Staff training 25

Incident Tracking Types of tracking systems Paper or electronic tracking systems Need to distinguish unresolved incidents Variables to track and trend Number of forms submitted overall Most frequent categories Changes over time 26

Sentinel Event Response 27

Sentinel Event Definition Incident that caused death or serious injury (physical or emotional) Near miss – incident that COULD have caused death or serious injury, even though this time it turned out OK Does not include adverse outcome due to natural course of illness Not the fault of an individual, multiple system failures 28

Examples of Sentinel Events Rape or sexual exploitation on-site Administering wrong medication Not following up on abnormal lab Dental extraction of wrong tooth Mis-diagnosis, missed diagnosis, delayed diagnosis Patient death immediately following a procedure 29

Incident Versus Sentinel Event Sentinel event is a type of incident – SEVERE Short-term response is the same as any incident Utilize same report form and reporting procedures Immediate response to individual incident Not looking at trends, looking at individual event Root cause analysis 30

Root Cause Analysis Ask WHY X 5 Team of 2 -3 people Complete RCA quickly Identify and correct systems failures Plan for human error Put backup systems in place 31

Case Study – Patient Suicide Document, investigate, respond, and report the event Identify root causes and system failures Poor communication Inconsistent scheduling Unclear task assignments Prevent recurrence 32

Final Thoughts on Improving Quality Identify potential problems Peer review Chart completeness Procedure audits / informed consent Patient satisfaction program Respond when things do go wrong Patient complaints Incidents Sentinel Events Implement in stages, full implementation within 1 year Develop a comprehensive program 33

Resources Bureau of Primary Health Care (BPHC) www.bphc.hrsa.gov Your State’s Primary Care Association / Organization www.bphc.hrsa.gov/osnp/PCADirectory Joint Commission on Accreditation of Healthcare Organizations (JCAHO) www.jcaho.org Institute for Healthcare Improvement (IHI) www.ihi.org 34

Contact Us With Questions National Association of Community Health Centers (NACHC) (301) 347-0400 contact@nachc.com www.nachc.com NACHC Managed Growth Assistance Program (Pamela Byrnes, Director) (860) 739-9224 pbyrnes@nachc.com Trudy Brown Ripin or Molly Gwisc from Shoreline Health Solutions (860) 395-5630 info@shsconsulting.net www.shsconsulting.net