# Presentation: 155430

## Comments heard about it

- Where do they come up with these things? Do they just pick them out of the air?
- Does anyone back there know what they are doing?
- It’s another top down mess
- I can’t believe that they think that they can tell us how to practice medicine
- They don’t know what they are talking about
- They want me to do what?
- Is there any money?

## Our Response: 

**GPRA BUSTERS**

## GPRA BUSTERS

- Where do they come up with these things?
- We make them up ( no.. They are based on goals)
- Does anyone back there know what they are doing?
- Well...
- I can’t believe that they think that they can tell us how to practice medicine
- No, we know that we can’t
- They don’t know what they are talking about
- Sometimes, but sometimes, we do
- They want me to do what?
- Don’t worry. We’ll tell you
- Is there any money?
- Mike Lincoln will answer that!

##  Clinical Quality Initiatives Impact on AI/AN health statusFebruary 2004 

** ****Clinical Quality Initiatives**** ****Impact on AI/AN health status****February 2004**** **

## We Can Change The World

- The Indian Health Service is committed to improving clinical outcomes by improving clinical quality

## Improving Quality of Health Care for AI/AN

- Objectives
- What affects clinical quality
- How do we measure clinical quality
- Quality of care indicators

## What affects Clinical Quality in the I/T/U setting? 

- Limited resources ( human, fiscal, administrative)
- Increasing User population
- Increasing disease burden ( obesity, diabetes, CVD, cancer, suicide, violence, alcohol and substance abuse)
- Budget increases do not keep pace with medical inflation
- Recruitment and retention issues  (e.g. dental)

##  What affects Clinical Quality in the I/T/U setting? 

- Concerned communities
- Caring and compassionate staff
- A sense of support
- Creating possibilities
- Embracing prevention and innovation
- Knowing the guidelines
- Knowing where the best practices are

## How do we measure clinical quality?

- Outcomes
- Content quality
- Technical and clinical expertise  (guidelines)
- Standards of care
- Delivery quality
- Interpersonal components of care
- Service quality
- Patients requirements and needs are met

## What interferes with our measurements?Kubler-Ross Stages of Performance Improvement

- “The data are wrong.”
- “The data are right, but it’s not a
-        problem.”
- “The data are right; it is a problem;
-        but it is not my problem.”
- “I accept the burden of
-       improvement.”

## So, what do we do?

- Recognize that the local facility( and staff) is where clinical quality begins
- Measure what is important to our communities in as passively as way as possible ( see indicators)
- Feedback information to the local level, as well as the regional and national level
- Use this information to assess  and report performance at these different levels, including Congress
- Link performance to the budget process
-     ( show how the I/T/U health care system
-       is a good investment)

## Clinical Quality Indicators

- indicator name
- how long has it been an indicator
- why is it an indicator
- what is the impact of achieving this indicator goal
- what is the likelihood that we can achieve this goal at a national level
- What is the likelihood that YOU can achieve this goal at your facility

## Diabetes Group

- Ideal control (FY 97 )
- Poor Control (FY 04)
- Blood Pressure Control  ( FY 97 )
- Nephropathy Screening (FY 97 )
- LDL screening (FY 97 )
- Retinopathy ( FY 03)

## Why are they indicators/ Impact of achieving- diabetes group 	

- Rationale:
- Diabetes is a major problem in AI/AN communities
- These indicators, as well as others in the diabetic audit, are standards of care
- Achievable goals
- Impact of Achieving:
- Reduce health disparities
- Improving diabetic blood sugar control will
- Save patients feet, kidneys, eyes, hearts, and lives
- Save money

## Cancer Screening Group

- PAP ( FY 99 )
- Mammogram ( FY 99 )

## Why are they indicators/ Impact of Achieving- Cancer Screening

- Rationale
- Higher rates of late diagnosis of breast and cervical cancer in AI/AN communities
- Later diagnosis means higher mortality
- Impact of Achieving
- Prevent cervical cancer
- Reduce the mortality and morbidity of cervical cancer and breast cancer

## AI/AN Age-Adjusted Cervical Cancer Mortality

**AI/AN Age-Adjusted Cervical Cancer Mortality**
**Rates, Compared to U.S. All Races, 1984-1998**

## Oral Health Group

- Access to care  ( FY 97))
- Diabetic access to care (FY 99)
- Dental Sealants (FY 01; changed in FY 02 to count numbers of sealants)
- Fluoridation ( FY ’99)

## Rationale / impact of achieving- dental group

- Rational
- High incidence of dental caries, which increases risk for other diseases
- Diabetes increases risk for periodontal disease
- Many communities without fluoridation
- Adequate teeth are essential for proper nutrition
- Impact of Achieving
- Prevent caries and teeth loss
-  Improve nutritional status
- Decrease morbidity and mortality

## Behavioral Group

- FAS Screening ( since FY 99; changes in FY 04 to screening women for alcohol use)
- Intimate Partner Violence ( since FY 99; changes in FY 04 to screening for DV in women)
- Suicide Prevention ( since FY 00; changes in FY 04 to implementation of national suicide prevention initiative)
- BH Data system utilization ( since FY 98)
- YRTC ( since FY 99; changes in FY 05 to accreditation)

## Rationale / impact of achieving- BH group

- Rationale
- FAS- high incidence
- IPV – every AI/AN female homicide in NM in CY 02 was a victim of IPV
- Suicide prevention – highest rate
- BH data system – limited BH data up to now for advocacy
- YRTC – ensure ongoing support
- Impact of Achieving
- Reduce health disparities
- Prevent FAS , IPV, suicide
- Improve outcomes for youth who are clients at YRTS
- Improve access to care as well as data

## Potpourri’ 

- Urban data ( FY 99)
- Accreditation ( FY 98)
- Consumer Satisfaction (FY 99)
- Medication Errors (FY 02)
- PHN Nursing Visits  ( FY 00)
- GPRA Passive Data Extraction- GPRA+
-    ( FY 01)

## Rationale/ Impact  of Achieving- Potpourri

- Rationale
- Desire to ensure comprehensive and quality care
- Morbidity and mortality associated with medication errors
- Desire for passive way to provide data to local facilities in a timely manner
- Impact of Achieving
- Improved quality of care
- Improved consumer and provider satisfaction

## Immunizations

- Childhood ( FY 99)
- Influenza ( FY 00)
- Pneumovax ( FY 03)

## Rationale/ Impact of Achieving – Immunizations 

- Rationale
- Childhood- reduce childood illness
- Influenza- reduce incidence of influenza
- Pneumovax- reduce pneumonia and other pneumococcal disease
- Impact of Achieving
- Reduction morbidity and mortality of specific  communicable diseases

## Prevention Group

- Obesity ( FY 99; changed in FY 04 to BMI measurement)
- CVD ( FY 01 pilot projects; changes in FY 05 to LDL screening in adults)
- Tobacco Cessation ( FY 00; FY 04 assess baseline screening rates)
- HIV ( FY 05- baseline screening in pregnancy)
- High Risk STD patients receive risk reduction counseling ( FY 04; no indicator in FY 05)

## Rationale/ Impact of Achieving – Prevention 

- Rationale
- Obesity, CVD , and tobacco use are major and increasing problems
- Identification of high risk patients with STD’s, and care of HIV patients is critical to ensuring adequate treatment and decreased tranmission
- Impact of Achieving
- Potentially reduce the rate of increase of these 3 major problems
- Impact on health disparities
- Increase utilization of cost- effective care ( for example, medical nutrition therapy)

## Increasing the likelihood of your facility achieving clinical quality goals

- Adopt an integrated approach to meeting the quality indicators
- Integrate guidelines into your practice via PCC+ or health maintenance reminders
- Use the clinical quality software to monitor your performance
- Check out the ‘toolbox’ on the web site
- Look for the best practices on the web site
- Celebrate ( and publish) your successes

## We Change the World

- No one else can take your place
- We can change the world
- Re-arrange the world
- Open up the door
- We can change the world...
-                                                     Nash 1970