1. Rapid Cycle Improvement Model Applied To Chlamydial Screening in Teens A Partnership Between: Kaiser Permanente Northern California & University of California, San Francisco Mary-Ann Shafer, MD Division of Adolescent Medicine UCSF Supported by the Agency for Health Care Research and Quality & the Centers for Disease Control and Prevention

2. Objectives Increase chlamydial (CT) screening of sexually active teen girls to meet HEDIS guidelines Develop, implement and evaluate a systems- based intervention that capitalizes on existing clinic resources while addressing barriers to CT screening using a rapid cycle approach

3. Background Facts About Chlamydia trachomatis (CT) CT-most common reportable STI in teens Most asymptomatic-in males and females NAATs- 90-95% sens & spec  feasible National Guidelines  annual CT screen (e.g. CDC, USPSTF, AAP, ACOG, AMA) Only 25% of eligible population being screened

4. JAMA December 11, 2002

5. Learning Objectives Learning Objectives Review the development, implementation and evaluation of a systems-based rapid cycle clinical improvement intervention (CPI) to increase CT screening Discuss the application of the CPI model to different clinical settings including identifying and overcoming barriers to success

6. Rapid Cycle Applied To CT Screen Recruit team Recruit team Problem solve at Problem solve at monthly meetings monthly meetings Apply solutions & Apply solutions & assess each month assess each month Repeat, sustain Repeat, sustain Time in months % Change in STD Screening Rate S t a t u s Q u o Rapid Cycle Changes

7. Step 1: Set Goal Set Goal Define measure Define measure Identify barrier(s) Identify barrier(s) Decide solution Decide solution Try it out Try it out Time in months % Change in STD Screening Rate S t a t u s Q u o Rapid Cycle Changes

8. Step 2 Assess trial Assess trial Identify next barriers Identify next barriers Decide solution Decide solution Try it out Try it out Time in months % Change in STD Screening Rate S t a t u s Q u o Rapid Cycle Changes

9. Step 3 Assess trial Assess trial Identify barriers Identify barriers Decide solution Decide solution Try it out Try it out Repeat “cycles” Repeat “cycles” Sustain gains Sustain gains Time in months % Change in STD Screening Rate S t a t u s Q u o Rapid Cycle Changes

10. Setting for Rapid Cycle Application Setting Large HMO in Northern California: KP 10 pediatric clinics randomly assigned: 5-well care intervention and 5 control groups 2 of 5 intervention clinics target both well and urgent care visits

11. Methods Urgent-Care Visit Same/next day visit Sick/non-ER visit 10 minute visit Same physical setting as WCV Same providers & staff as WCV KP Pediatric Setting cont. Well-Care Visit Appointment required Physical exam (every 2-3 yrs) 20 minute visit

12. Engage Team Building Re-Design Clinical Practice Sustain the Gain Clinical Practice Improvement Model

13. Engage Team Building Re-Design Clinical Practice Sustain the Gain Leadership Best practices Define gap Raise Awareness

14. Engage Team Building Re-Design Clinical Practice Sustain the Gain ACTeam Skill building Tool Kit Clinical Practice Improvement Model

15. Engage Team Building Re-Design Clinical Practice Sustain the Gain Customize Measure success Clinical Practice Improvement Model

16. Engage Team Building Re-Design Clinical Practice Sustain the Gain Monitor performance Time series analysis Continuous improvement Clinical Practice Improvement Model

17. Urines To Lab MD/NP VISIT Room Patient MA refrigerates FVUs  A enters teen name, confidential # in clinic log book  LRunner takes FVU to lab MD/NP obtains sex hx If sexually active, MD completes CT lab slip  W  WWrites confid. # on chart MA collects FVU on all 14-18 yo F  TTeen takes FVU sample to exam room Cue Charts ID eligible teens  C Charts are stamped with cue Follow- Up RN contacts CT + teen: confid. # Teen comes to clinic for Rx RN enters Rx in STD log book Site Specific Flow Chart

18. 1. Cue Charts  IIdentify eligible (target) population (14-18 y teens)  Charts stamped with cue (Y2P!) CC

19. 2. Room Patient  M MA collects FVU on all 14-18 yo  TTeen takes FVU sample to exam room  a CC

20. 3. VISIT  CMD/ NP obtains sexual hx  IIf sexually active, MD completes CT lab slip  WWrites confidential phone number on chart CC

21. 4. Urines to Lab  CMA refrigerates FVUs  MA enters teen name, confidential phone number in log book  LRunner takes FVU to lab CC

22. 5. Follow-up RN contacts CT + teen: confidential phone number Teen comes to clinic for Rx RN enters Rx into STD log book CC

23. Clinician’s Top Barriers to CT Screening in Primary & Urgent Care Settings 1.CONFIDENTIALITY: How separate parent? 2.TEEN SEX HX: How do I ask these things? 3.PRIORITIES: How competes in urgent care? 4.JOB DESCRIPTION: Is this part of my job? 5.PAYMENT: Who’s responsible? 6.POSITIVE CT RESULT: What do I do now?

24. Confidentiality Universal urine collection Teen’s sexual history Teen-friendly rooming policy Site Teen Health Champion Anonymous chart reviews Priorities for limited time Re-think visit priorities Payment – copays Waived to protect teens small price to pay! Positives tests FU protocol in place Key Barriers Sample Solutions

25. RESULTS Female CT Screening Rates* Pediatric Well-Care Visits (14-18 yo) *Chlamydia Screening Rate = #CT Tests/(#Well Care Visits *Sexual Activity Rate

26. RESULTS: Female CT Screening Rate in Urgent Care Pilot Sites % SA Females Screened for CT A A A B B B

27. Results of Intervention Evaluation Dramatic improvement in well & urgent clinics Sustainable & cost-effective Clinic differences in approach  rate of improvement varies One solution does not fit all even within HMO

28. Implications Rapid cycle  quick, customized & sustained Effective in different settings- well, urgent care & may be applied as a quality assurance tool Capitalizes upon existing resources & staff Small changes  LARGE effects Gives chronically over-worked staff sense of importance, success & control over workplace