Rapid Cycle Quality Improvementfor STD Services in theUSHealthcare System

Maxine Henderson, RN BSQuality Improvement Director

Community Health Center Model

Family HealthCare Center - Fargo

Federally qualified 501(c3) Community Health Center

Small border city in rural area of ND/MN

Joint Commission Accredited – Ambulatory Care

Services• 2 Family Practice Clinic sites• 2 Dental Clinics• Homeless Health Service• Native American Programs• Medical Interpreter Service – serves city• Concordia College Student Health

Service• Cass/Clay County jails

• Serve 20 different cultures• Interpret 13 different languages

Patient Demographics:

Ages

20-44 Yrs44%

13-19 Yrs14%

5-12 Yrs10%

Under 5 Yrs12%

Over 64 Yrs3%

45-64 Yrs17%

80% of ptsunder theage of 45 yrs

Ethnicity

Racial Mix - 2002

White55%

Middle Eastern & Eastern European

11%

American Indian / Alaskan Native

9%

Hispanic12%

Asian2%

Unreported / Unknown

3%Black*

8%

Patient Population Served

>11,000 patients

>1900 females 15-25 years

94% below 200% poverty level

34 % are uninsured

37% receive Medical Assistance

Performance Improvement

Rapid Cycle Improvements for

Chronic Disease Management

Prevention ServicesChlamydia Screening

BPHC Collaboratives

The (Chronic) Care ModelEd Wagner, MD McColl Institute – Seattle

Model for ImprovementPDSA (Plan-Do-Study-Act) CyclesAssociates in Process Improvement

4 years

Key Improvements

Organization of HealthCareAdministrative support•Staff time •Financial resources

Improvement in health outcomes becomes part of Strategic PlanComponent of new employee/provider orientation

Decision Support

Use of Clinical Guidelines•Embedded throughout clinic practice•Part of annual provider competency

evaluation•Linked to incentive raises

Clear Measurable goals

Increased access to expertise•Continual education for providers/clinical staff•Specialists available for consultation

Delivery System Design

Forms which trigger compliance with practice standards“Planned visits”Standing ordersMultidisciplinary approach

Clinical Information SystemsPatient tracking and follow-up

Self-Management Support

Risk assessments

Learning needs assessments

Shared decision making – Patient goal setting

Improved patient education

•Standards of Care– Disease states

– Prevention for age group

Community Resources

Partnerships with other organizations•Public Health•Red River Dental Access•Extension Services•Local Universities / Schools

Grants to support special projects•$$$$ available for prevention

activities

Improved Health Outcomes

>400 patients with Diabetes

Average A1c 9.79 to 7.69

Average Cholesterol 232 to 186

Average systolic B/P 155 to 137

> 200 patients with Asthma

After 4 session Asthma Education Program

Understanding of meds 56% to 100%

Perform home peak flow 25% to 94%

Written Asthma Action Plan 6% to 100%

Use of spacer 33% to 87%

Spread

Once you learn how to use rapid cycle improvements in all components of The Care Model, it is easy to Spread:Spread:

DepressionCardiovascular DiseasePerinatalRefugee Health

PREVENTION -PREVENTION - Current area of Spread Pilot: 5 CHCs – BPHC – CDC – IHI

•Healthy Weight Management•Physical Exercise•B/P Screening•Cholesterol Screening•Oral Health •Lead Screening• Immunizations

•Chlamydia ScreeningChlamydia Screening

Chlamydia & GC Screening - 2003

Total Female patients 15-25 yrs.- 1906

Pap smear 15-25 yrs. – 542 (28%)

Chlamydia Screening 15-25 yrs. - 428

79% of those having Paps

8% Positive 8% Positive + (3 pos. gonorrhea)

Chlamydia & GC Screening >26 yrs.

–

316 pts.

1% Positive 1% Positive

• + (4 pos. gonorrhea)

Confirms…..

AgeAge is the single biggest

predictor of Chlamydia infection in

our clinic

Opportunity for ImprovementVariance:

The 72% of 15-25 year old female patients that were not

scheduled for a pap smear at our clinic

Unknown:

How many of these adolescents were referred to and seen

at Public Health for testing

Patients Referred

FHC Clinics are in same building as Public Health Dept. at both sites

Adolescents who don’t want parents to know, or bill to be sent, are referred to PH

ConfidentialSliding Fee Scale on adolescent’s income – so usually free or a donation

Public Health Dept. Screenings

Chlamydia Screenings – 20032,865 tests done203 (7.08%) positive for Chlamydia

What % of these were adolescents referred by Family HealthCare Center?

Performance Improvement PlanDeveloped Clinical Guidelines for

Management of Chlamydia Infection

Provider EducationGuidelines Clinic Baseline Statistics

Goal: Increase screening for females 15-25 yrs. by 100%

Expanded Teen Risk Assessment Form

Made screening affordableMN Teen Program - $15 (exam, pap, screen)•Confidential

$9 regular charge for test

Evaluating need for urine screening

Improved education materials on Chlamydia

Set-up monthly tracking process# females – paps – screenings - % positiveAdolescent referrals to Public Health

Prevention Collaborative

Family HealthCare Center-Fargo 

PDSA Cycle # 28Increase Number of Chlamydia Screenings Done with Routine Paps

Jan. 2004  

PLAN ObjectiveIncrease the number of Chlamydia screenings done on female patients

15-25 years old who are being seen for a routine pap and physical. 

PredictionWe will be able to achieve a >95% screening rate, by doing provider

staff education and amking small changes in the supply set-up for routine paps.

Plan for test: who, what, when, whereReview Clinical Guidelines with provider and nurse who will conduct test Remind provider to include routine screen on all female patients 15-25 years, and all at-risk females >26 years.Add Gen-Probe Collection Kit and Lab Request Form to room set-up list for

routine pap and physical 

Plan for collection of data:QI Dir. – on Monday afternoon, run test provider’s schedule for next dayMark all routine paps and physicals on patients 15-25 yearsAsk test provider’s nurse to mark on the schedule if a Chlamydia screen

was done, and return schedule to QI Dir. at end of day.

 

DO Monday pm - provider’s schedule was run and paps for next day on 15-25 year old female patients were marked. Tuesday am – huddled with provider and nurse to review schedule. Reminded nurse to put out Gen-Probe swab and lab slip for

each scheduled pap that day. Instructed nurse to mark schedule if Chlamydia screen was done along with exam.

 STUDY By reviewing last year’s screening statistics and the new Clinical

Guidelines with the provider, she agreed we missed easy opportunitiesfor screening. 100% of patients (5 patients age 17-24 years) werescreened for Chlamydia during this test. Having the Gen-Probe Collectionkit and lab slip laid out reminded the provider to do the test.

 

ACT Wednesday – repeated test with a different provider and nurse: again100% of targeted patients were screened. Reviewed procedure withall providers and nursing staff, and procedure implemented as a Standard of Practice in our health center.

Barriers to Improvement

Lack of patient education materials in many languages

Many refugees illiterate – even in primary language

Inconsistent adherence to Clinical Guidelines by clinic providers – resistance to change

Resources need for new equipment

Increase staff time needed for registry data entry

Uninsured patients unable to pay for all tests/services recommended

Orientation of new providers and staff