Sponsored by the National Association of Community Health Centers

1. Sponsored by the National Association of Community Health Centers Presented By Shoreline Health Solutions, LLC Trudy Brown Ripin, MPH President & Founder Molly K. Gwisc, MPH Associate Performance Improvement in Community Health Centers

2. Presentation Goals • Understand Performance Improvement methodology, as well as practical techniques for quality improvement. • Effectively use the PI model in a new start Community Health Center • Review case studies to demonstrate PI in real scenarios • Understand proactive and reactive performance improvement strategies

3. Improving Performance • How do we know we are providing high quality care and services? • Do we set and achieve appropriate and realistic goals? • How do we measure improvement?

4. What is Performance Improvement? • Performance Improvement (PI) is a continuous, systematic process for improving the agency’s care, service and operations.

5. Why do Performance Improvement? • Methodological way to ensure high quality care & patient safety • Tells you if changes worked • PI model gives you concrete steps to simplify a complex process • BPHC and JCAHO require it

6. What If We Don’t Measure? • You won’t know if the change WORKED • You won’t know WHICH PART of the change worked • You could make things WORSE • Others may NOT BELIEVE the change worked

7. Selecting a PI Project • Triggered by a specific incident • Based on existing data trends • Prioritizing: High Risk, High Volume, Problem Prone • Directly impacts patient care or patient satisfaction

8. Key Elements of a PI Model • Establish baseline • Set benchmark • Make change • Measure your change • Follow-up

9. FOCUS - PDSA • PDSA is one of many models for PI • Four - step cycle to plan and measure change • FOCUS component maps out Pre-Work to PDSA

10. FOCUS Find a process to improve Organize a team Clarify what is currently happening (baseline data) Understand where and why problems occur Select the process improvement and benchmark

11. PDSA Plan the Performance Improvement strategy Do a trial run, collect data as you go Study your results Was there a measurable improvement? If not, go back to PLAN until benchmark is achieved Act! Ongoing monitoring for sustained improvement

12. Operational PI Examples • Patient Wait Time • Patient Satisfaction • Staff Satisfaction • Claims Denial • Collections

13. Operational PI Case Study Improving Patient Wait Times F Chose wait times in response to patient demand - patient complaints O Formulated team involved in areas of wait time – included a clinical provider, medical assistant, registration staff, billing staff, senior management C Collected baseline data through wait time study U Understood problem areas by clarifying where delays occur - delays occurred at registration, waiting in exam room, and billing S Selected to de-centralize intake as first process improvement – benchmark is reducing wait time by 20 minutes.

14. Operational PI Case Study Improving Patient Wait Times P Plan thoroughly developed and outlined by team D Plan implemented in pediatrics S Data collected and not at benchmark – repeat cycle A Benchmark achieved!! Implemented changes in all departments

15. High Level Integration • An effective PI program incorporates all data sources through a central PI Committee and integrated PI Program infrastructure.

16. PI Committee Structure • Select Representative Members • Integrate into all sites • Meet regularly • Appoint PI Coordinator • Complete assignments between meetings • Select 1-2 PI Priorities Annually • Appoint PI Teams • Ensure Ongoing Monitoring • Review Key Data Trends From All Sources

17. Components of PI Program Proactive Strategies • Peer Review • Chart Completeness Review • Informed Consent – High Risk Procedures • Patient Satisfaction Reactive Strategies • Incident Tracking • Patient Complaint Tracking • Sentinel Event Response

18. Peer Review • Providers Review Each Other’s Charts • Standardized Audit Tool • Identify Trends • Report Results to Staff and Leadership

19. Peer Review Goals • Review Individual Trends Over Time • Review Clinical Practice Trends • Answer Specific Clinical Questions

20. Chart Completeness Review • Evaluates Medical Record Documentation • Checklist is Standardized • Usually Done Monthly • Can Be Done By Non-Clinical Staff

21. High Risk Procedures – Informed Consent • What is a High-risk Procedure? • Risk Of Serious Complications • Examples Include Perforation & Infection • Informed Consent Needed • Understand Benefits & Risks • Be Informed Of Alternatives • Good Clinical Care • Liability Protection/ Risk Management

22. Patient Satisfaction Program • Components of a Comprehensive Pt Satisfaction Program • Surveys • Staff Training • Patient Suggestion/Comment Box • Patient Complaint Tracking System

23. Incident Tracking • Documenting the Event • Incident Review • Resolving the Incident • Identifying Trends

24. Patient Complaint Tracking • Identifies customer service and communication problems • Utilizes same process as Incident Tracking • Rapid response to each complaint • Feedback to patient describing agency response • Complaint patterns indicate systemic problems • Structured response to systems problems

25. Sentinel Event Response • What is a sentinel event? • Near Miss • Do Not Wait for a Trend • Root Cause Analysis

26. Clinical PI Examples • Triage: • Child with 104 degree fever scheduled for next day appointment • Walk-in patient left waiting for 2 hours when should have been sent to ER • Evaluation • Missed Diagnosis • Mis-Diagnosis • Labs not ordered • Treatment • Wrong medication prescribed • Perforation during IUD insertion

27. Clinical PI Examples • Lab Issues • Patient given wrong person’s test results • Lab tests ordered, but never done • Results never come back from outside lab • Controlled Substances • Stolen prescription pads / forged prescriptions • Patient seeing multiple providers / pharmacies to obtain controlled substances

28. Clinical PI Examples • Chart Documentation • Illegible handwriting • Provider seeing patient without chart • Phone/ Communication • Provider never receives patient message • Language and cultural barriers

29. Clinical PI Case Study Follow-Up for Abnormal Labs F Identified problem through incident tracking. O Team included Medical Director, Nurse Coordinator, Medical Assistant, Lab Tech, staff person receiving mail / fax / delivery of lab results. C Baseline data collected via lab testing log, 3 week period reviewed. U Problem areas included use of multiple outside labs, high volume, part-time clinicians, no clear person in charge of process. S Identified responsible person to track all abnormal labs. Benchmark set at 100% follow-up rate within 24 hours of notification.

30. Clinical PI Case Study Follow-Up for Abnormal Labs P Plan thoroughly developed and outlined by team. D Implemented for three providers S Data collected: 24-hour follow-up achieved for 95% of cases. Not at benchmark – repeat cycle. A Benchmark achieved!! Implemented changes for all providers.

31. Resources • NACHC www.nachc.org • BPHC www.bphc.hrsa.gov • JCAHO www.jcaho.org • Institute for Healthcare Improvement www.ihi.org • Your State’s Primary Care Association/Organization • Contact us with questions (Trudy or Molly, Shoreline Health Solutions) info@shsconsulting.net or (860) 395-5630