Structure, Process and Outcomes

1. A DISCUSSION ABOUT THE WHAT, WHEN, HOW AND WHY OF QUALITY ASSURANCE/QUALITY IMPROVEMENT Jacki Witt, JD, MSN, WHNP-BC, SANE-A Structure, Process and Outcomes

2. DISCLOSURES • Watson, Afaxys and Agile Advisory Boards • Thanks to Mike Policar, MD, MPH, for sharing his expertise and data re: California PACT QA measures and to Susan Moskosky, Acting Director, OPA for sharing expertise and information regarding Title X

3. QUALITY?

4. Background:Title X Program Guidelines • Original guidelines established in 1970 following the enactment of Public Health Service Act 42 U.S.C. 300 authorizing the establishment of the Title X program • Current guidelines were updated in 1980 and in 2001 • Address largely legal and regulatory requirements of Title X program

5. Two parts to the guidelines under development 1) Program Requirements: Defines program requirements for grantees funded under the Title X program – primarily statutory and regulatory. • Guidance for Providing Quality Family Planning Services Recommends how to provide family planning services in an evidence-based manner

6. Purpose of the Title X Program Guidelines • To assist current and prospective grantees in understanding and utilizing the family planning service grants program: • Grant application and award process • Project management & administration • Financial management • Clinic management and clinical service requirements • Although primary target audience of the guidelines is Title X grantees, these guidelines serve as a “standard of care” for other stakeholders

7. New Opportunities • The Title X guideline revision has occurred in the context of the Affordable Care Act: • Increased access must be accompanied by improved quality • Emphasis on accountability, health outcomes and evidence-based approach • Standards needed on which to base performance measurement

8. Why develop national family planning recommendations? • To support consistent application of quality care across settings and provider types • To translate research into practice, so the most evidence-based approaches are used

9. Conceptual Framework • Improved QUALITY of care  improved RH outcomes • Quality care is safe, effective, client-centered, timely/accessible, efficient and equitable (IOM 2001) • Also addresses choice of methods, information given to clients, technical competence, interpersonal relations, mechanisms to encourage continuity (Bruce 1990, Becker 2007)

10. Goals of the Title X Guidance Revision Process • Utilize best evidence to design preventive services • Prioritize provision of corefamily planning services • Allow flexibility for recommended services • Avoid services where harms exceed benefits • Support client decisions re: services received or declined • Remove barriers to care for the client and provider • Improve clinic efficiency • Anticipate changes in source of primary care arising from the Affordable Care Act

11. Relationship to other U.S. guidelines • U.S. Medical Eligibility Criteria for Contraceptive Use (CDC) • Safety of contraceptive practice • U.S. Selected Practice Recommendations (CDC) • Contraceptive management, e.g., exams needed, missed pills, etc. • Quality family planning services (Title X/CDC) • Focus on how to deliver services, e.g., counseling, outreach, QA/QI, special populations, other services • Platform to highlight key practice implications of MEC and SPR

12. MMWR May 28, 2010 Focus on safety in women with a variety of medical conditions

13. MMWR June 21, 2013 Focus on efficacy in women and men using contraceptives

14. U.S. Selected Practice Recommendations for Contraceptive Use, 2013 • Removing unnecessary barriers can help patients access and successfully use contraceptive methods • Several medical barriers to initiating and continuing contraceptive methods might exist, such as • Unnecessary screening examinations and tests before starting the method (e.g., a pelvic examination) • Inability to receive method on the day of the visit • Difficulty obtaining continued contraceptive supplies (e.g., pill packs dispensed at one time)

15. Evidence Based Guidelines for Family Planning CDC MEC 2010 CDC SPR 2013 CDC STD Treatment Guidelines 2010 Contraceptive Practice STD Practice F screening M screening Preconception Fertility enhancement Preg determination Title X Guidance 2013

16. Strengthening Clinical Aspects of Care

17. Framework for Family Planning and Related Preventive Services

18. Determine the need for services Flow Diagram of Family Planning & Related Services Initial reason for visit is not related to preventing or achieving pregnancy Reason for visit is related to preventing or achieving pregnancy Acute care Chronic care management Preventive services Contraceptive Services Pregnancy testing and counseling Achieving Pregnancy Basic infertility services Assess need for services related to preventing or achieving pregnancy If needed, provide services STD services Preconception health services Clients should also be offered these services, as needed If services are not needed at this visit, re-assess at subsequent visits Related preventive health services Clients should also be offered or referred for these services, as needed

19. Contraceptive Services • Remove medical barriers to contraceptive use!!! • Offer a full range of FDA-approved methods • Use a tiered approach to counseling, with the most effective methods mentioned first & embedded within counseling framework described earlier • Consider whether client is at low or high risk of unintended pregnancy • Low: using long-acting reversible methods or more effective methods with an established history of continuation • High: using a less effective method and/or has a history of poor rates of continuation

20. Clinical Barriers to Contraceptive Services • Lack of awareness of family planning guidelines • Unnecessary screening tests • Limits on same day availability of methods • Inappropriate restriction on U.S. Medical eligibility criteria Category-3 methods • Diversion of limited time from family planning services to provide non-reproductive primary care

21. Summary The new family planning guidelines should: • Improve the quality of family planning services in the U.S. • Encourage more research to strengthen the evidence base for specific strategies and services • Provide a platform to expand other essential preventive services to women and men

22. QUALITY ASSURANCE/IMPROVEMENT

23. Selecting Indicators for YOUR Clinic • Use evidence based resources to determine indicators for quality care

25. * If adequate prior screening with negative results Co-test: cervical cytology plus hrHPV test Cytology: cervical cytology (Pap smear) alone

26. Quality Indicators(from CA Family PACT) Must meet all of the following criteria • Clinically relevant topic • Intervention that will measure an outcome or a process to improve outcomes • Objectively measurable • Performance is under the influence of the provider • Ability to compare provider performance to peer group or benchmark (or both) over time intervals

27. Indicators • Quality indicators • Chlamydia screening rates < 25 years old • Chlamydia screening rates > 25 years old • Utilization indicators • Annual reimbursement per client • Annual office visits per client • % of visits coded at highest level • New patients (99204) • Established patients (99214)

28. Indicators • Quality indicators • Cervical cytology intervals • Utilization indicators • Number, percentage and demographics of patients leaving with a method • Patient volume trends over time • Total Clients • Teen Clients • Male Clients • New Clients

29. Provider Profile Indicators • Family planning quality metrics • Access to Tier 1 contraceptives • Use of Tier 1 contraceptives as a percentage of all clients using a method in FY • Initiation of Tier 1 contraceptives as a percentage of all clients initiating a method in FY • Below average number implies poor access • Percent of clients using Tier 3 methods only during Y • Above average number implies poor counseling or poor access to higher Tier methods

30. Framework for Quality Improvement

31. P - D - S - A • Plan • Choose indicators • How will data be collected, by whom, etc. • How will results be disseminated? • Do • Collect data • Study • All members of the team have input • Act • Initiate a new system for tracking

32. Routine Cancer Screening in Women ACOG: Am College of Ob-Gyn ACS: American Cancer Society CBE: Clinical breast exam CDC: Centers for Disease Control USPSTF: US Prev Services Task Force

33. Routine STI Screening

34. Routine Metabolic Screening ATP: Adult Treatment Panel CHD: coronary heart disease

35. Plan for Data Collection • WHO • WHAT • WHEN • HOW

36. Plan for Dissemination of Results • The more the merrier • Not punitive • Emphasis is on improvement of processes, outcomes and efficiency • All focused on bottom line, not just management

37. Dissemination of Family Planning Recommendations • At MMWR now, expected release by end of 2013 • Key federal agencies • Title X providers, 4400 clinics serving 5 million low income clients/year • Community Health Centers, 1100 clinics serving 19 million low income clients/year • Major professional organizations, such as: • American Academy of Pediatrics • American College of Ob/Gyn • American College of Family Medicine

38. References • Deming, WE. The New Economics for Industry, Government, Education. (1993 )