Documenting Current Screening Processes

1. Documenting Current Screening Processes Improvement Facilitation Session 1 Day 2

2. Objectives • To understand why we document current screening processes • To review and assess methods for documenting a provider’s or clinic’s currently screening practices

3. Why document “current” processes?

4. If you can’t describe what you are doing as a process, you don’t know what you are doing. • W. Edwards Deming Where are we starting from?

5. ASaP Screening Methods Opportunistic A process designed to identify patients who are due for screening when they come in for any appointment.

6. Screening Methods Outreach A process designed to “comb” the panel for those who are due or overdue for screening, then use that list to invite patients for a screening appointment.

7. Vulcan Medical Clinic - example • Dr. Shawn Webster (lead physician) • Suzie Mitchell (PCN RN/POET) • Participated in HSiA, TRaC II, EPICS IIb • Engaged TOP for screening process redesign (BP, Diabetes, Obesity, COPD)

8. EPICS IIb Vulcan Medical Clinic: Cancer Screening Process (Pre-intervention) Clinic Assistant Physician • As required: • Offers PAP • Offers mammoreq • Offers FOBT req &/or • Refers for scope • Selects HSiA template Yes Escorts patient to exam room • Documents in chart • Completes encounter PHE? No • Addresses patient concerns • Addresses Ca screening if patient asks

9. EPICS IIb Vulcan Medical Clinic: Cancer Screening Process (Opportunistic) Physician Clinic Assistant POET • Checks CA’s notes • Discusses with pt, as needed • Colonoscopy referral, as appropriate Documents in chart to complete encounter • reviews at request of CA • checks scanning nomenclature • searches Netcare • corrects in chart • updates Rules, as needed • Discrepancy in chart? • messages POET • ‘Colorectal Due’ • prints req for FOBT • makes note for physician • Documentation • records in chart notes • SMART forms record automatically Escorts patient to exam room Checks ‘Rules’ on Patient Chart • ‘PAP Due’ • books appnt with physician or NP • ‘Mammo Due’ • prints req for pt

10. For Example (EMR, Telus-Wolf)

11. EPICS IIb Vulcan Medical Clinic: Cancer Screening Process (Outreach) Clinic Assistant POET • q. 3 months • Runs report of women due for PAP Reviews list for accuracy • Contacts Patients • phones to remind of screening due Documents contact in patient chart Alerts POET of unrecorded PAPs Exempts patients from search rule, as appropriate

12. For Example (EMR, Telus-Wolf)

13. EPICS IIb Results% of age/gender appropriate patients to whom screening was offered • 50 patient charts per review (October, December, March) • Patients having presented for an encounter and due for screening • Including outreach screening for cervical • Females (21-74 years), Males (50-74 years)

14. Documenting Current State As with Vulcan’s journey, the first step is to establish where they currently are PROCESS MAPPING

15. Simple Process Mapping Step 1: Name the process Step 2: Determine the starting point and the end point Step 3: Brainstorm what happens between Step 4: Arrange the steps in order

16. Example Step 1: Name the process “Preparing tea for mother-in-law”

17. Example Step 2: Determine the starting point and the end point Get kettle Present cup to M-i-L

18. Example Step 3: Brainstorm what happens between Add water Pour tea in cup Wait for whistle Pour water in teapot Plug kettle in Wait 5 minutes Place tea bags in teapot Get milk from fridge Get cup Add sugar Remove lid Remove tea bags Pour milk in cup

19. Example Add sugar Step 4: Arrange the steps in order Get kettle Remove lid Add water Plug kettle in Get the tea box Open the box Place tea bags in teapot Wait for whistle Pour water in teapot Wait 5 minutes Present cup to M-I-L Pour tea in cup Remove tea bags Pour milk in cup Get milk from fridge Get cup

20. Key Points • Start and end steps are clearly defined (oval shape) • Steps are all “actions” (start with a verb) • Limit the time spent brainstorming – 15 minutes • Request that one team member writes the steps on post-it notes • Request that another team member positions the steps • Take a picture of the post-its to capture the process

21. BMFC Map Current Screening Process Screening if patient requests (physician) MOA rooms patient No Patient greeted by reception Address confirmed PHE? MOA measures Ht/Wt MOA brings up CPX template Yes Physician enters MOA leaves MOA enters Ht/Wt Physician completes CPX maneuvers Completes exam, closes chart

22. BMFC Reception Blue Meadow Family Care – Current Screening Process MOA Physician Screening if patient requests Rooms patient No Greets patient PHE? Confirms address Yes Measures Ht/Wt Opens CPX template Completes maneuvers as per CPX Enters room Leaves room Records Ht/Wt Finishes exam, closes chart

23. Discussion – Process Mapping BMFC I think I only see a height and weight on about ½ of my patients - I end up doing it myself! Your Name Here (IF) I tried running a report on height & weight and got low numbers of screens. I’m not really sure where to chart height and weight. There’s more than one place where they can go.

24. Alternate Option

25. Discussion – Guided Interview BMFC Sometimes I discuss screening with patients, but I don’t always chart what I’ve offered – especially if they decline. Your Name Here (IF) In reality, I only screen patients when they book a PHE. Otherwise, I generally don’t think of it unless prompted… We have room for improvement - even some patients who are here frequently aren’t getting screened.

26. Discussion • What differences did you note between the two methods? • When do you think you might choose the simple process mapping method for ASaP? • When do you think you might choose the guided interview method for ASaP?

27. McDonalds Patent Application“Method and Apparatus for Making a Sandwich”

28. Summary • Part of the IF role is to guide clinic teams in documenting their current screening processes • This establishes the starting point for developing or enhancing opportunistic and/or outreach screening processes • Depending on the situation, simple process mapping or a guided interview method may be used