Sponsored by the National Association of Community Health Centers Presented By Shoreline Health Solutions, LLC Trudy Brown Ripin, MPHPresident & Founder Molly K. Gwisc, MPHAssociate Performance Improvement in Community Health Centers

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

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?

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

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

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

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

Key Elements of a PI Model 1. Establish baseline 2. Set benchmark 3. Make change 4. Measure your change 5. Follow-up

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

FOCUS F ind a process to improve O rganize a team C larify what is currently happening (baseline data) U nderstand where and why problems occur S elect the process improvement and benchmark

PDSA P lan the Performance Improvement strategy D o a trial run, collect data as you go S tudy your results Was there a measurable improvement? If not, go back to PLAN until benchmark is achieved A ct! Ongoing monitoring for sustained improvement

Operational PI Examples Patient Wait Time Patient Satisfaction Staff Satisfaction Claims Denial Collections

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.

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

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

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

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

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

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

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

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

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

Incident Tracking Documenting the Event Incident Review Resolving the Incident Identifying Trends

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

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

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

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

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

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.

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.

Resources NACHCwww.nachc.org BPHCwww.bphc.hrsa.gov JCAHOwww.jcaho.org Institute for Healthcare Improvementwww.ihi.org Your State’s Primary Care Association/Organization Contact us with questions (Trudy or Molly, Shoreline Health Solutions) or (860)