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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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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
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)
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
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
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
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
Staff credentials and training
Policy and procedures
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
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
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)
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
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)
Data are systematically aggregated and analyzed on an ongoing basis
Improved performance is achieved and sustained.
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
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
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.
US Preventive Services Task Force
American Academy of Family Physicians
Emphasis on prevention and education
Certain conditions/issues appear over and over
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?
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)
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
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
Adolescent Preventive Care (14-18 year olds)
Health care use
Health and safety
Health care in the last 12 months
Reliable and valid
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
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.
Children with special healthcare needs
Children in foster care
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
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
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
DOJ Federal Collaboration on What Works (prevention, intervention, treatment for juvenile justice, drug and ETOH)
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
“…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)
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
Openness drives improvement
Well being of patients is paramount
People should be able to learn anything that affects their lives
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
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
Academic Success: with the school
Productivity: with stakeholders
CQI Tool: with insurers and employers
…now with users and families.
The Bell Curve, Atul Gawande (2004) http://www.newyorker.com/fact/content/?041206fa_fact
When Things Go Wrong (Harvard teaching institutions) http://www.ihi.org/NR/rdonlyres/A4CE6C77-F65C-4F34-B323-20AA4E41DC79/0/RespondingAdverseEvents.pdf
Pursuing Perfection- Cincinnati Children's
“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)
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.
NASBHC (Principles, CQI Tool, MHPET, Collaboratives, Productivity)
Standards, Principles, Program Evaluation, and Evaluation of Clinical Care
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
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
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.
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?
34 indicator measure which evaluates eight dimensions related to providing mental health services in schools
Staff and training
Identification, referral and assessment
School coordination and collaboration
Community coordination and collaboration
Quality assessment and improvement
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
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
Annual risk assessment and physical exam
Risk for Type 2 diabetes
Poor School Performance
Annual risk assessment and physical exam
Risk for Type 2 diabetes
Poor School Performance
Data collection forms
Guide to sampling populations
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
Lack of parental involvement
Forces the providers to address the “hard” issues
SBHC needs the partnerships/referral relationships to support providing preventative services
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
A prevention mission
A supportive environment for students
A competent staff
Collaborative partnerships for prevention
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
Compare yourself to other apples not oranges
Document the SBHC experience for improvement and advocacy
CQI ( revision in 2008)
Productivity ( on web www.nasbhc.org)
Cost ( in development, contact [email protected] if interested in participating in beta test)
MH PET ( on web www.nasbhc.org)