1. Improving the Quality of Prenatal Care at the WMed FM Residency Clinic Susan Jevert, DO Homer Stryker MD School of Medicine Department of Family and Community Medicine Kalamazoo, MI

2. Disclosures I have no conflicts to disclose

3. Objectives On completion of this session, the participants should be able to: –Understand how to implement standardized OB care into their clinic and apply this to other areas of care –Understand ACGME scholarly activity requirement –Identify possible areas for quality improvement within their program –Identify ways to motivate students & residents to participate in quality improvement

4. Our Clinic Western Michigan University Homer Stryker MD Family Medicine Residency Clinic (WMed) is housed in a federally qualified health center (FQHC) The safety net for medical care, including obstetrical care, in Kalamazoo County

5. Our Patients

6. Hypothesis The quality of prenatal care provided in our resident clinic can be improved through standardization of care and quarterly physician feedback.

7. Methods Design : Cohort study in which adherence to the current obstetrical standards of care was considered

8. Methods Protocol: –A standardized "check list” of 22 areas of prenatal screening and education was developed based on current ACOG, AAFP and CDC guidelines –Completed chart reviews of OB patients who received prenatal care in our clinic between July, 2012 and December, 2014, who met our inclusion criteria, to establish baseline data –Trained providers on our prenatal care "check list” –Collected data for one year after the “check list” was implemented based on completion rates of the various elements of OB screening and education

9. Methods Inclusion criteria: –Patients who established for prenatal care and delivered with Team Oakland –Patients who did not receive prenatal care elsewhere after establishing with Team Oakland –169 patients met our inclusion criteria for the retrospective portion and 130 for the implementation phase

10. Methods Exclusion criteria –Patients who transferred care prior to delivery –Any testing or education indicated per guidelines before the patient established care with Team Oakland were not taken into consideration

11. Methods Statistical analysis: Compared pre and post implementation data using Chi-Square test of independence and Fishers exact test

12. Results Statistically significant improvement in 8 of 22 areas of prenatal screening and education Overall improvement from 58.66% to 72.2%

13. Pre-InterventionPost-InterventionDifferenceP Value NPercentageN Overall230558.66%156572.20%+13.55%<0.0001 PHQ9 Screening at 1 st visit1620.62%13021.54%+20.92%<0.0001 OB Panel @ 1st visit157100.00%119100.00%+0.00% 1 Gonorrhea & Chlamydia Testing @ 1st visit15887.34%12092.50%+5.16% 0.1634 Test of Cure for Chlamydia1770.59%1392.31%+21.72% 0.1563 Offered HIV Screening @ 1st visit15692.31%11996.64%+4.33% 0.1285 PAP Screening if Indicated @ 1st visit10389.32%6490.63%+1.30% 0.7863 Urine Culture @ 1st visit or 12-16wks15771.97%12087.50%+15.53% 0.0018 Offered Quad Screening @ 15-20wks11873.73%7578.67%+4.94% 0.4360 Offered Anatomy ultrasound @ 18-21wks11972.27%7582.67%+10.40% 0.0973 Repeat Hg/Hct @ 24-28wks12754.33%8260.98%+6.64% 0.3435 1hr GTT @ 24-28wks13769.34%8673.26%+3.91% 0.5314 3hr GTT if needed1190.91%1492.86%+1.95% 0.6967 Rhogam @ 27-29 weeks666.67%6 +0.00% 0.7273 Repeat antibody screen prior to Rhogam633.33%3 +0.00% 0.7273 Repeat Chlamydia (3rd trimester if high risk)1656.25%1894.44%+38.19% 0.0121 Repeat HIV (3rd trimester if high risk)160%1861.11%+61.11% 0.0001 GBS Screening @ 35-37wks13070.00%8368.67%-1.33% 0.8377 Complete 1st trimester education12726.77%7835.9%+9.13% 0.1672 Complete 2nd trimester education14822.97%9160.44%+37.47% <0.0001 Complete 3rd trimester education13611.03%8848.86%+37.83% <0.0001 Tdap Vaccine @ 27-36wks13551.85%8672.09%+20.24% 0.0028 Flu vaccine16354.60%7475.68%+21.07% 0.0020

14. Results Figure 4. Comparison of pre and post compliance rates.

15. Conclusion We proved our hypothesis by demonstrating an improvement in the quality of prenatal care provided in our clinic through standardization of care and quarterly physician feedback

16. Limitations and Barriers to Success Patient non-compliance with keeping scheduled appointments Resident buy-in with the checklist Small sample sizes for several measures

17. Ideas Standardization of pediatric well child visit Standardization of diabetic care MA/Resident communication forms OB patient scheduling/call schedule

18. Scholarly Activity The curriculum must advance residents’ knowledge of the basic principles of research, including how research is conducted, evaluated, explained to patients, and applied to patient care Residents should complete 2 scholarly activities, at least one of which should be a quality improvement project

19. “I don’t care about research”

20. Quality Improvement Projects Easy to get IRB approval/exemption Allows residents to have a say if how things are done

21. Tips for Success Help them find something they are passionate about Teach PDSA cycles Know your resources Use your faculty advisors Offer resident incentive for presenting at a conference

22. Acknowledgments We would like to thank the Western Michigan University Homer Stryker MD School of Medicine Department of Family Medicine and the Department of Epidemiology and Biostatistics for their assistance with this project. This study was approved as exempt on December 8, 2014 by the IRB committee at Bronson Methodist Hospital.

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