Linda Juszczak, Interim Executive Director – NASBHC Tiffany A. Clarke, Program Associate – NASBHC September 21, 2008

1. Linda Juszczak, Interim Executive Director – NASBHC Tiffany A. Clarke, Program Associate – NASBHC September 21, 2008 Quality Improvement in SBHCs

2. Objectives Define terms and processes related to quality Review standards of care for children and adolescents Review national quality improvement initiatives related to children and adolescents Review standards of care in school health Identify measures of quality in school health Develop a strong comfort level as a trainer with this content

3. The Components of Quality How to measure? What to measure? Standards: What is the grade or level of quality?

4. Definitions Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (Institute of Medicine, 1990). Quality assessment is the act of measuring quality of care, of detecting problems of quality, or of finding examples of good performance.

5. Definitions Quality assurance applies to an entire cycle of assessment which extends beyond problem identification, to verification of the problem, identification of what is correctable, initiation of interventions, improvements, and continual review to assure that identified problems have been adequately corrected and that no further problems have been engendered in the process.

6. Definitions Quality Improvement seeks to improve performance not just areas of unacceptable care. Quality improvement focuses on the processes of health care delivery and use of statistical approaches designed to reduce variations in those processes. (CQI, TQI)

7. Evidence Based Decision Making • Care should be based on: • the best available scientific knowledge and • should not vary illogically from clinician to clinician or from place to place. Institute of Medicine ( IOM, 2006)

8. The Process of Quality Improvement

9. Methods: Quality by Inspection Theory of bad apples Find the bad apples and remove them Implies or establishes a threshold for acceptability People are the cause of troubles Mortality data are used

10. Methods: Theory of Continuous Improvement Problem is rarely related to the people but to the process or the job design, failure of leadership, or unclear purpose Need to understand and revise the production process Use a variety of measures

11. Methods: PDSA Cycle and Fundamental Questions for Improvement What are you trying to accomplish? How do you know if change = improvement? What changes will result in improvement? Langley et al, The Improvement Guide, 1996

12. Act Plan Do • State objective of the cycle • Make predictions • Develop plan to carry out cycle (who, what, where, when.) • What changes are to be made? • What will be the next cycle? Study • Complete the analysis of the data. • Compare data to predictions. • Summarize what was learned. • Carry out the test. • Document the problems and unexpected observations. • Begin analysis of the data. PDSA Cycle

13. Repeated Use of the Cycle Changes That Result in Improvement A P S D DATA D S P A A P S D A P S D Hunches Theories Ideas

14. PDSA Cycle Group Activity

15. What Do You Measure? Structural Measures - the physical, financial and organizational properties in which care is provided Process measures - what is actually done in giving and receiving care and whether what is now known as “good” medical care has been applied Outcome Measures - the effects of care on health status, knowledge, behavior and patient satisfaction (Donabedian, 1966,1988,1992)

16. Examples of Measures : Structural Staff credentials and training Physical environment Policy and procedures Supervisory practices

17. Examples of Measures Tests, treatment and clinical strategies in use Comparison to a standard Protocols Total quality management methodologies Focus on process through use of tools such as: process flow diagrams, cause& effect diagrams Process Measures

18. Examples of Measures: Outcomes Morbidity Mortality Patient Knowledge Patient Satisfaction

19. Joint Commission How care is delivered not prescriptive on content of care - encourage best practice and innovation Addresses level of performance for activities that affect the quality of care Evaluates based on a set of standards of care, have to be in compliance with applicable standards AND intent of the standards Analyze and evaluate the systems that drive operations and procedures

20. Joint Commission Focus on activities with high volume, a degree of risk and that tend to produce problems for staff or patients, and/or are costly Need to establish a threshold for evaluation Frequency of data collection and review is based on the significance of the event and the extent to which data reflects improvement Can compare to other organization to improve performance (Benchmarking) http://www.jcaho.org/standards

21. Joint Commission - Standards Patient focused functions Patient rights and organizational ethics Assessment of patients Education Continuum of care Linguistically and culturally appropriate care Organizational focused functions Structures with functions

22. Some “Hot” Areas –Joint Commission Environment of care - is space equipped to provide care Patient education activities (food-drug-drug/drug interactions, anticipatory guidance) Medication management to reduce error Patient outcomes- vigorous analysis of practice Documentation in medical record Patient safety (new 7/01 now majority of standards)

23. Joint Commission - Improving Organizational Performance Data are systematically aggregated and analyzed on an ongoing basis Improved performance is achieved and sustained.

24. Joint Commission Beginning January 1, 2006, on-site surveys for accredited ambulatory care organizations and office-based surgery practices will be unannounced. NP and PA credentialing process is becoming increasingly important

25. HEDIS 2009 • Weight assessment and counseling for nutrition and physical activity for children • Childhood immunization • Chlamydia screening • Appropriate testing for children with pharyngitis • Appropriate treatment for children with upper respiratory infection • Follow up care for children prescribed with ADHD medication

26. HEDIS 2009 • Children with chronic conditions • Children and adolescent access to primary care practitioners • Use of appropriate medications for people with asthma • Follow up after hospitalization for mental illness • Medical assistance with smoking cessation • Annual dental visit

27. Chart Reviews How many?- < 30 visits do 100%, 30- <600 do 10%, > 600 do 5% Need to be done to monitor medical and behavioral health record compliance- NCQA, Joint Commission, Insurance companies Do focused reviews at the same time- CQI Tool or others

28. What else do you need to do? A person on staff is responsible for CQI Monitor the environment of care Written policies and procedures in place Written scope of care Patient satisfaction measured periodically Regular tracking of key variables to monitor operations: no shows, cancellations, new to revisit ratio, apt to walk in ratio.

29. Discussion

30. Selecting a Standard of Care

31. Guidelines for Review US Preventive Services Task Force Bright Futures GAPS American Academy of Family Physicians

32. Standards of Care : Themes Comprehensive Periodic Emphasis on prevention and education Certain conditions/issues appear over and over

33. Considerations In Guideline Selection Age of your patient population Characteristics of your clinical practice Practicality of implementing in your practice Are there tools that can be used effectively? Are there systems in place to document and measure quality?

34. Quality Improvement Initiatives Related To Children And Adolescents

35. An Emerging National Agenda Crossing the Quality Chasm (IOM, 2001) National Health Care Quality Report (IOM, 2001) National Academy of Science call for system of rewards based on performance ( NY Times, October 31st, 2002)

36. FACCT (The Foundation for Accountability- Closed) Dedicated to helping consumers have information they need to make better decisions about their health care. Formulates measures that consumers find relevant and easy to understand. Child and Adolescent Health Measurement Initiative (CAHMI) - measure development Young Adult Health Care Survey Living with Illness Promoting Healthy Development Measures tested, submitted to HEDIS, used for plan QI, consumer information development, and research studies

37. Child and Adolescent Health Measurement Initiative (CAHMI) - Young Adult Health Care Survey (YAHCS) Measures not just receiving care but the quality of care that adolescents receive for accountability purposes Collaboration between NCQA, AAP, Children Now!,CDC, AHRQ, etc Focus is on preventive care and align with national recommendations Adolescents’ asked directly about the care they received

38. CAHMI - YAHCS Adolescent Preventive Care (14-18 year olds) 56 questions Health care use Privacy Health and safety Health information Health care in the last 12 months Your health Demographics Reliable and valid http://dch.ohsuhealth.com/index.cfm?pageid=451&sectionID=133&open=148

39. Consumer Assessment of Health Plan Survey (CAHPS) Instrument in development that is intended to capture information about the experience and satisfaction adolescents’ report about basic aspects of care such as access and communication with providers. Shares 20 items with YAHC Parents complete survey first then have adolescents complete https://www.cahps.ahrq.gov/default.asp

40. NICHQ: National Initiative for Child Health Quality An action-oriented organization dedicated solely to improving the quality of health care provided to children. Mission is to eliminate the gap between what is and what can be in health care for all children. http://www.nichq.org

41. NICHQ: National Initiative for Child Health Quality Asthma ADHD Children with special healthcare needs Children in foster care Preventive care Cultural competency Obesity http://www.nichq.org

42. 2005 National Health Care Disparities Reports Proportion of children whose parents report getting advice on physical activity is lower among poor and near poor children. Childhood asthma admission rates are highest among black children Many racial and ethnic minorities and persons of lower socioeconomic position are less likely to receive childhood immunizations

43. Issues Influencing Mental Health and CQI Limited evidence base and variations in care especially for children Diversity of providers Characteristics that distinguish mental health from general health care Characteristics of SBHC practice Charting Less well developed infrastructure for quality measurement

44. Organizations And Initiatives Conducting Systematic Evidence Reviews Related To Mental Health Cochrane Group (developmental, psychosocial and learning problems) USPSTF (suicide risk) National Registry of Evidence Based Programs and Practice (brand name programs for prevention, CBT, multisystemic therapy) Agency for Healthcare Research and Quality (AHRQ) - ADHD

45. Organizations and Initiatives Conducting Systematic Evidence Reviews DOJ Federal Collaboration on What Works (prevention, intervention, treatment for juvenile justice, drug and ETOH) Professional Associations

46. How Organizations Respond To Problems And Opportunities To Improve Pathological: hide information, shoot the messenger, cover failures, crush new ideas Bureaucratic: ignore information, tolerates messengers, promotes self as just and merciful, new ideas= problems Generative: information is sought, messengers are trained, failures lead to inquiry , new ideas are welcomed (Westrum,2004)

47. The Learning Organization “…organizations where people continually expand their capacity to create the results they desire, where new and expansive patterns of thinking are nurtured, where collective aspiration is set free, and where people are continually learning to see the whole together.”(Senge,1990)

48. The Learning Organization There is a process of self examination and continuous improvement Openness and collaboration (patient centered care) The best have the capacity to learn, adapt and improve the fastest

49. Patient centered care Openness drives improvement Well being of patients is paramount People should be able to learn anything that affects their lives

50. Why be transparent? Leads to greater improvement Involves parents and users Includes a view of why problems exist that you would not have considered before There is by in from all involved to improve