# Presentation: 177029

## Rapid Cycle Quality Improvementfor STD Services in theUSHealthcare System

***Rapid Cycle Quality Improvement******for STD Services in the******USHealthcare System***

**Maxine Henderson, RN BS**
**Quality 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:

**80% of pts**
**under the**
**age of 45 yrs**

## Ethnicity

## 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 Services
- Chlamydia Screening

## BPHC Collaboratives

- The (Chronic) Care Model
- Ed Wagner, MD    McColl Institute – Seattle
- Model for Improvement
- PDSA (Plan-Do-Study-Act) Cycles
- Associates in Process Improvement
- 4 years

## Key Improvements

- Organization of HealthCare
- Administrative support
- Staff time
- Financial resources
- Improvement in health outcomes becomes part of Strategic Plan
- Component 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

- 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 orders
Multidisciplinary approach

Clinical Information Systems
Patient tracking and follow-up

- Forms which trigger compliance with practice standards
- “Planned visits”
- Standing orders
- Multidisciplinary approach
- Clinical Information Systems
- Patient 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

- 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

- 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%

*   **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:***
- Depression
- Cardiovascular Disease
- Perinatal
- Refugee Health

## 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 Screening

- Pilot: 5 CHCs – BPHC – CDC – IHI
- Healthy Weight Management
- Physical Exercise
- B/P Screening
- Cholesterol Screening
- Oral Health
- Lead Screening
- Immunizations
**Chlamydia 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   **+ (3 pos. gonorrhea)**       **

## Chlamydia & GC Screening >26 yrs. –  
          316 pts.
 1% Positive  
 + (4 pos. gonorrhea)

-           _316 pts._
** ****1% Positive  **
** **+ (4 pos. gonorrhea)

## Confirms.....

**   ****Age** is the single biggest predictor of Chlamydia infection in our clinic

## Opportunity for Improvement

- Variance:
-    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
- Confidential
- Sliding Fee Scale on adolescent’s income – so usually free or a donation

## Public Health Dept. Screenings

- Chlamydia Screenings – 2003
- 2,865 tests done
- 203  (7.08%) positive for Chlamydia
- What % of these were adolescents referred by Family HealthCare Center?

## Performance Improvement Plan

- Developed Clinical Guidelines for Management of Chlamydia Infection
- Provider Education
- Guidelines
- Clinic Baseline Statistics
- Goal: Increase screening for females
-        15-25 yrs. by 100%

## Expanded Teen Risk Assessment Form
Made screening affordable
MN 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 - % positive
Adolescent referrals to Public Health

- Made screening affordable
- MN 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 - % positive
- Adolescent referrals to Public Health

## 	                                                                                            Prevention Collaborative

**	****                                                                                            ****Family HealthCare Center-Fargo**
** **
**PDSA Cycle # 28**
**Increase Number of Chlamydia Screenings Done with Routine Paps**
**Jan. 2004**
** **
** **
**PLAN**	_Objective_
- 	Increase the number of Chlamydia screenings done on female patients
-                         15-25 years old who are being seen for a routine pap and physical.
- 	_Prediction_
- 	We 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, where_
- 	Review 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 day
- 	Mark all routine paps and physicals on patients 15-25 years
- 	Ask 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 opportunities
- 	for screening.  100% of patients (5 patients age 17-24 years) were
- 	screened for Chlamydia during this test.  Having the Gen-Probe Collection
- 	kit and lab slip laid out reminded the provider to do the test.
**ACT**	Wednesday – repeated test with a different provider and nurse:  again
- 	100% of targeted patients were screened.  Reviewed procedure with
- 	all 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

- Increase staff time needed for registry data entry
- Uninsured patients unable to pay for all tests/services recommended
- Orientation of new providers and staff