Documenting Current Screening Processes Improvement Facilitation Session 1 Day 2

Objectives To understand why we document current screening processes To review and assess methods for documenting a provider’s or clinic’s currently screening practices

Why document “current” processes?

If you can’t describe what you are doing as a process, you don’t know what you are doing. – W. Edwards Deming Where are we starting from?

ASaP Screening Methods Opportunistic A process designed to identify patients who are due for screening when they come in for any appointment.

Screening Methods Outreach A process designed to “comb” the panel for those who are due or overdue for screening, then use that list to invite patients for a screening appointment.

Vulcan Medical Clinic - example Dr. Shawn Webster (lead physician) Suzie Mitchell (PCN RN/POET) Participated in HSiA, TRaC II, EPICS IIb Engaged TOP for screening process redesign (BP, Diabetes, Obesity, COPD)

Physician Documents in chart Completes encounter Documents in chart Completes encounter EPICS IIb Vulcan Medical Clinic: Cancer Screening Process (Pre-intervention) Escorts patient to exam room Clinic Assistant Clinic Assistant Selects HSiA template Addresses patient concerns Addresses Ca screening if patient asks Addresses patient concerns Addresses Ca screening if patient asks PHE ? As required: Offers PAP Offers mammo req Offers FOBT req &/or Refers for scope As required: Offers PAP Offers mammo req Offers FOBT req &/or Refers for scope Yes No

Physician Documents in chart to complete encounter EPICS IIb Vulcan Medical Clinic: Cancer Screening Process (Opportunistic) Escorts patient to exam room POET ‘ Mammo Due’ prints req for pt ‘ Mammo Due’ prints req for pt ‘ PAP Due’ books appnt with physician or NP ‘ PAP Due’ books appnt with physician or NP Clinic Assistant Clinic Assistant Checks ‘Rules’ on Patient Chart Checks CA’s notes Discusses with pt, as needed Colonoscopy referral, as appropriate Checks CA’s notes Discusses with pt, as needed Colonoscopy referral, as appropriate Documentation records in chart notes SMART forms record automatically Documentation records in chart notes SMART forms record automatically ‘ Colorectal Due’ prints req for FOBT makes note for physician ‘ Colorectal Due’ prints req for FOBT makes note for physician reviews at request of CA checks scanning nomenclature searches Netcare corrects in chart updates Rules, as needed reviews at request of CA checks scanning nomenclature searches Netcare corrects in chart updates Rules, as needed Discrepancy in chart? messages POET Discrepancy in chart? messages POET

For Example (EMR, Telus-Wolf)

EPICS IIb Vulcan Medical Clinic: Cancer Screening Process (Outreach) q. 3 months Runs report of women due for PAP q. 3 months Runs report of women due for PAP POET Documents contact in patient chart Contacts Patients phones to remind of screening due Contacts Patients phones to remind of screening due Clinic Assistant Clinic Assistant Reviews list for accuracy Alerts POET of unrecorded PAPs Exempts patients from search rule, as appropriate

For Example (EMR, Telus-Wolf)

EPICS IIb Results % of age/gender appropriate patients to whom screening was offered 50 patient charts per review (October, December, March) Patients having presented for an encounter and due for screening Including outreach screening for cervical Females (21-74 years), Males (50-74 years) Chart ReviewCervicalBreastColorectal Pre-intervention 74%85%80% Post-intervention 94%100%88% Sustainability 100%

Documenting Current State As with Vulcan’s journey, the first step is to establish where they currently are PROCESS MAPPING

Simple Process Mapping Step 1: Name the process Step 2: Determine the starting point and the end point Step 3: Brainstorm what happens between Step 4: Arrange the steps in order

Example Step 1: Name the process “Preparing tea for mother-in-law”

Example Step 2: Determine the starting point and the end point Get kettle Present cup to M-i-L

Example Step 3: Brainstorm what happens between Plug kettle in Pour tea in cup Pour milk in cup Get milk from fridge Place tea bags in teapot Get cup Pour water in teapot Wait 5 minutes Remove tea bags Wait for whistle Add sugar Remove lid Add water

Example Step 4: Arrange the steps in order Plug kettle in Pour tea in cup Pour milk in cup Get milk from fridge Place tea bags in teapot Get cup Pour water in teapot Wait 5 minutes Remove tea bags Wait for whistle Get kettle Present cup to M-I-L Add sugar Open the box Get the tea box Remove lid Add water

Key Points Start and end steps are clearly defined (oval shape) Steps are all “actions” (start with a verb) Limit the time spent brainstorming – 15 minutes Request that one team member writes the steps on post-it notes Request that another team member positions the steps Take a picture of the post-its to capture the process

Map Current Screening Process 21 Patient greeted by reception PHE? Screening if patient requests (physician) MOA brings up CPX template MOA enters Ht/Wt MOA measures Ht/Wt MOA rooms patient Address confirmed MOA leaves Physician enters Physician completes CPX maneuvers Completes exam, closes chart No Yes BMFC 

Blue Meadow Family Care – Current Screening Process Greets patient Confirms address PHE? Rooms patient Screening if patient requests Measures Ht/Wt Opens CPX template Records Ht/Wt Leaves room Enters room Completes maneuvers as per CPX Finishes exam, closes chart No Yes Reception MOA Physician BMFC 

Discussion – Process Mapping 23 Dr. Doe (physician) Dr. Green (physician) Doreen (receptionist ) Maureen (office manager) Chris (MOA) Your Name Here (IF) I tried running a report on height & weight and got low numbers of screens. I’m not really sure where to chart height and weight. There’s more than one place where they can go. I think I only see a height and weight on about ½ of my patients - I end up doing it myself! BMFC 

Alternate Option

Discussion – Guided Interview 25 Dr. Doe (physician) Dr. Green (physician) Doreen (receptionist ) Maureen (office manager) Chris (MOA) Your Name Here (IF) In reality, I only screen patients when they book a PHE. Otherwise, I generally don’t think of it unless prompted… We have room for improvement - even some patients who are here frequently aren’t getting screened. Sometimes I discuss screening with patients, but I don’t always chart what I’ve offered – especially if they decline. BMFC 

Discussion What differences did you note between the two methods? When do you think you might choose the simple process mapping method for ASaP? When do you think you might choose the guided interview method for ASaP?

McDonalds Patent Application “Method and Apparatus for Making a Sandwich”

Summary Part of the IF role is to guide clinic teams in documenting their current screening processes This establishes the starting point for developing or enhancing opportunistic and/or outreach screening processes Depending on the situation, simple process mapping or a guided interview method may be used