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Linda Juszczak, Interim Executive Director – NASBHC Tiffany A. Clarke, Program Associate – NASBHC September 21, 2008. Quality Improvement in SBHCs. Objectives. Define terms and processes related to quality Review standards of care for children and adolescents

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Linda Juszczak, Interim Executive Director – NASBHC

Tiffany A. Clarke, Program Associate – NASBHC

September 21, 2008

Quality Improvement in SBHCs


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

the components of quality
The Components of Quality

How to measure?

What to measure?

Standards: What is the grade or level of quality?


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.


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.


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)

evidence based decision making
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)
methods quality by inspection
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

methods theory of continuous improvement
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

methods pdsa cycle and fundamental questions for improvement
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




  • 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?


  • 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

repeated use of the cycle
Repeated Use of the Cycle


That Result















what do you measure
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)

examples of measures structural
Examples of Measures : Structural

Staff credentials and training

Physical environment

Policy and procedures

Supervisory practices

examples of measures
Examples of Measures

Tests, treatment and clinical strategies in use

Comparison to a standard


Total quality management methodologies

Focus on process through use of tools such as: process flow diagrams, cause& effect diagrams

Process Measures

examples of measures outcomes
Examples of Measures: Outcomes



Patient Knowledge

Patient Satisfaction

joint commission
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

joint commission20
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)

joint commission standards
Joint Commission - Standards

Patient focused functions

Patient rights and organizational ethics

Assessment of patients


Continuum of care

Linguistically and culturally appropriate care

Organizational focused functions

Structures with functions

some hot areas joint commission
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)

joint commission improving organizational performance
Joint Commission - Improving Organizational Performance

Data are systematically aggregated and analyzed on an ongoing basis

Improved performance is achieved and sustained.

joint commission24
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

hedis 2009
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
hedis 200926
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
chart reviews
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

what else do you need to do
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.

guidelines for review
Guidelines for Review

US Preventive Services Task Force

Bright Futures


American Academy of Family Physicians

standards of care themes
Standards of Care : Themes



Emphasis on prevention and education

Certain conditions/issues appear over and over

considerations in guideline selection
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?

an emerging national agenda
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)

facct the foundation for accountability closed
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

child and adolescent health measurement initiative cahmi young adult health care survey yahcs
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

cahmi yahcs

Adolescent Preventive Care (14-18 year olds)

56 questions

Health care use


Health and safety

Health information

Health care in the last 12 months

Your health


Reliable and valid§ionID=133&open=148

consumer assessment of health plan survey cahps
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

nichq national initiative for child health quality
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.

nichq national initiative for child health quality41
NICHQ: National Initiative for Child Health Quality



Children with special healthcare needs

Children in foster care

Preventive care

Cultural competency


2005 national health care disparities reports
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

issues influencing mental health and cqi
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


Less well developed infrastructure for quality measurement

organizations and initiatives conducting systematic evidence reviews related to mental health
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

organizations and initiatives conducting systematic evidence reviews
Organizations and Initiatives Conducting Systematic Evidence Reviews

DOJ Federal Collaboration on What Works (prevention, intervention, treatment for juvenile justice, drug and ETOH)

Professional Associations

how organizations respond to problems and opportunities to improve
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


the learning organization
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)

the learning organization48
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

patient centered care
Patient centered care

Openness drives improvement

Well being of patients is paramount

People should be able to learn anything that affects their lives

why be transparent
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

what needs to happen in order to be transparent
What needs to happen in order to be transparent

Commitment to change

Creation of a culture of transparency


Re train staff

Regular reporting mechanism

Project level data – it is not about the individual

Opportunities to practice being transparent


The blame game

Fear users will stop using the service

Fears regarding loss of position -status, jobs etc

recommendations from nasbhc share your improvement data
Recommendations from NASBHC: Share your improvement data

Academic Success: with the school

Productivity: with stakeholders

CQI Tool: with insurers and employers

…now with users and families.

learning more about a culture of transparency
Learning more about a culture of transparency

The Bell Curve, Atul Gawande (2004)

When Things Go Wrong (Harvard teaching institutions)

Pursuing Perfection- Cincinnati Children's

the patient has a right to transparency
The patient has a right to transparency

“Nothing about me without me”

Caregivers have no moral or legal authority to withhold information

Withholding information is arrogant and disrespectful

Not knowing causes anger, resentment and loss of trust

(Leape, Atlanta, IHI IMPACT Mtg May 2006)

pay for performance
Pay for Performance

The goal of pay-for-performance programs should be to align reimbursement with the practice of high quality, safe health care for all consumers.



Cost reduction vs incentives

Becoming more widely implemented. Providers in HMOs being paid based on their performance.

standards of care for sbhcs
Standards of Care for SBHCs




NASBHC (Principles, CQI Tool, MHPET, Collaboratives, Productivity)

best practice in sbhcs

Best practice in SBHCs:

Standards, Principles, Program Evaluation, and Evaluation of Clinical Care

principles for sbhcs
Principles for SBHCs

Supports the school

Responds to the community

Focuses on the student

Delivers comprehensive care

Advances health promotion activities

Implements effective systems

Provides leadership in adolescent and child health

a program evaluation tool for sbhcs
A Program Evaluation Tool for SBHCs

The 7 principles and their goals

Structures needed to implement the goals - the physical and organizational properties of the environment

Processes to support the goals - what is done to achieve the desired outcome

Outcomes that can be attributed to a desirable performance - satisfaction, behavior,morbidity

examples of outcomes
Examples of Outcomes

Reduced number of students who leave school during the day due to illness

High parent satisfaction

Increased enrollment for and utilization of SBHC services

Patient perception that well-being has improved

Increased compliance rates as measured by follow-up visits completed, prescriptions filled, therapy attended, referrals completed etc.

questions regarding measurement of quality in sbhcs
Questions Regarding Measurement of Quality in SBHCs

Are the things we want to measure truly important to the health of students?

Do the measures identify good health and care?

Can clinical practice make an impact on these conditions?

Are the measures practical?

Do they work in the field?

mental health planning and evaluation template mhpet
Mental Health Planning and Evaluation Template (MHPET)

34 indicator measure which evaluates eight dimensions related to providing mental health services in schools


Stakeholder involvement

Staff and training

Identification, referral and assessment

Service delivery

School coordination and collaboration

Community coordination and collaboration

Quality assessment and improvement

evaluation of clinical services in sbhcs cqi tool
Evaluation of Clinical Services in SBHCs (CQI Tool)

Sentinel conditions as a marker of the quality of clinical care

The foundation is an annual risk assessment and biennial physical exam

Limited number of conditions allows for meaningful evaluation

Intent is for the tool to be flexible

the sbhc cqi tool

Six conditions per age group (choose one of two mental health conditions)

References to support the inclusion of the condition and to use to improve performance

Resources necessary to provide quality care relative to that sentinel condition

Markers of care for that condition

Measurement of the markers on a scale of 1 to 5 with threshold at 3

sentinel conditions for elementary school cqi tool
Sentinel Conditions for Elementary School (CQI Tool)

Annual risk assessment and physical exam


Risk for Type 2 diabetes

Poor School Performance

Oral Health

Mental health


Psychological trauma

sentinel conditions for middle school and high school cqi tool
Sentinel Conditions for Middle School and High School (CQI Tool)

Annual risk assessment and physical exam


Risk for Type 2 diabetes

Tobacco use

Substance use

Chlamydia screening


Poor School Performance

Oral Health

Mental health


Psychological trauma

sbhc cqi tool

The tool

Data collection forms



Guide to sampling populations

why is improving practice a problem
Why Is Improving Practice a Problem?

The demand for services keeps you reacting to crises and acute care requests

Lack of administrative support (school and SBHC operations/budget)

Effect on productivity

why is improving practice a problem73
Why Is Improving Practice a Problem?


Lack of parental involvement

Forces the providers to address the “hard” issues

SBHC needs the partnerships/referral relationships to support providing preventative services

why does it matter
Why Does It Matter?

Consistent with a standard of care

Realizes the potential of the SBHC model

Valued by insurers, government, parents, the community and students themselves (?)

Focused on finding adolescents at risk or already in trouble

Staff satisfaction

essential elements for successful prevention in sbhcs nasbhc
Essential Elements for Successful Prevention in SBHCs (NASBHC)

A prevention mission

A supportive environment for students

A competent staff

Collaborative partnerships for prevention

Effective strategies


factors associated with successful adoption of innovations organizational adopters
Factors Associated with Successful Adoption of Innovations: Organizational Adopters

Decentralized decision making

Can identify, capture, share and integrate new knowledge

Receptive to change through strong leadership, clear vision, good management and climate conducive to experimentation and risk taking

Effective data systems

Ready for change

Greenhalgh et al 2004

nasbhcs benchmarking efforts
NASBHCs Benchmarking Efforts

Compare yourself to other apples not oranges

Document the SBHC experience for improvement and advocacy


CQI ( revision in 2008)

Productivity ( on web

Cost ( in development, contact [email protected] if interested in participating in beta test)

MH PET ( on web