Sponsored by the

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Performance Improvement in Community Health
Centers

• Sponsored by the
• National Association of Community Health Centers
• Presented By Shoreline Health Solutions, LLC
• Trudy Brown Ripin, MPH President Founder
• Molly K. Gwisc, MPH Associate

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Presentation Goals

• Understand Performance Improvement methodology,
  as well as practical techniques for quality
  improvement.
• Effectively use the PI model in a new start
  Community Health Center
• Review case studies to demonstrate PI in real
  scenarios
• Understand proactive and reactive performance
  improvement strategies

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Improving Performance

• How do we know we are providing high quality care
  and services?
• Do we set and achieve appropriate and realistic
  goals?
• How do we measure improvement?

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What is Performance Improvement?

• Performance Improvement (PI) is a continuous,
  systematic process for improving the agencys
  care, service and operations.

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Why do Performance Improvement?

• Methodological way to ensure high quality care
  patient safety
• Tells you if changes worked
• PI model gives you concrete steps to simplify a
  complex process
• BPHC and JCAHO require it

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What If We Dont Measure?

• You wont know if the change WORKED
• You wont know WHICH PART of the change worked
• You could make things WORSE
• Others may NOT BELIEVE the change worked

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Selecting a PI Project

• Triggered by a specific incident
• Based on existing data trends
• Prioritizing High Risk, High Volume, Problem
  Prone
• Directly impacts patient care or patient
  satisfaction

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Key Elements of a PI Model

1. Establish baseline
2. Set benchmark
3. Make change
4. Measure your change
5. Follow-up

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FOCUS - PDSA

• PDSA is one of many models for PI
• Four - step cycle to plan and measure change
• FOCUS component maps out Pre-Work to PDSA

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FOCUS

• Find a process to improve
• Organize a team
• Clarify what is currently happening (baseline
  data)
• Understand where and why problems occur
• Select the process improvement and benchmark

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PDSA

• Plan the Performance Improvement strategy
• Do a trial run, collect data as you go
• Study your results
• Was there a measurable improvement?
• If not, go back to PLAN until benchmark is
  achieved
• Act! Ongoing monitoring for sustained
  improvement

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Operational PI Examples

• Patient Wait Time
• Patient Satisfaction
• Staff Satisfaction
• Claims Denial
• Collections

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Operational PI Case Study

• Improving Patient Wait Times
• F Chose wait times in response to patient demand
  - patient complaints
• O Formulated team involved in areas of wait time
  included a clinical provider, medical
  assistant, registration staff, billing staff,
  senior management
• C Collected baseline data through wait time
  study
• U Understood problem areas by clarifying where
  delays occur - delays occurred at registration,
  waiting in exam room, and billing
• S Selected to de-centralize intake as first
  process improvement benchmark is reducing wait
  time by 20 minutes.

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Operational PI Case Study

• Improving Patient Wait Times
• P Plan thoroughly developed and outlined by team
• D Plan implemented in pediatrics
• S Data collected and not at benchmark repeat
  cycle
• A Benchmark achieved!! Implemented changes in
  all departments

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High Level Integration

• An effective PI program incorporates all data
  sources through a central PI Committee and
  integrated PI Program infrastructure.

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PI Committee Structure

• Select Representative Members
• Integrate into all sites
• Meet regularly
• Appoint PI Coordinator
• Complete assignments between meetings
• Select 1-2 PI Priorities Annually
• Appoint PI Teams
• Ensure Ongoing Monitoring
• Review Key Data Trends From All Sources

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Components of PI Program

• Proactive Strategies
• Peer Review
• Chart Completeness Review
• Informed Consent High Risk Procedures
• Patient Satisfaction
• Reactive Strategies
• Incident Tracking
• Patient Complaint Tracking
• Sentinel Event Response

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Peer Review

• Providers Review Each Others Charts
• Standardized Audit Tool
• Identify Trends
• Report Results to Staff and Leadership

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Peer Review Goals

• Review Individual Trends Over Time
• Review Clinical Practice Trends
• Answer Specific Clinical Questions

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Chart Completeness Review

• Evaluates Medical Record Documentation
• Checklist is Standardized
• Usually Done Monthly
• Can Be Done By Non-Clinical Staff

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High Risk Procedures Informed Consent

• What is a High-risk Procedure?
• Risk Of Serious Complications
• Examples Include Perforation Infection
• Informed Consent Needed
• Understand Benefits Risks
• Be Informed Of Alternatives
• Good Clinical Care
• Liability Protection/ Risk Management

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Patient Satisfaction Program

• Components of a Comprehensive Pt Satisfaction
  Program
• Surveys
• Staff Training
• Patient Suggestion/Comment Box
• Patient Complaint Tracking System

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Incident Tracking

• Documenting the Event
• Incident Review
• Resolving the Incident
• Identifying Trends

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Patient Complaint Tracking

• Identifies customer service and communication
  problems
• Utilizes same process as Incident Tracking
• Rapid response to each complaint
• Feedback to patient describing agency response
• Complaint patterns indicate systemic problems
• Structured response to systems problems

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Sentinel Event Response

• What is a sentinel event?
• Near Miss
• Do Not Wait for a Trend
• Root Cause Analysis

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Clinical PI Examples

• Triage
• Child with 104 degree fever scheduled for next
  day appointment
• Walk-in patient left waiting for 2 hours when
  should have been sent to ER
• Evaluation
• Missed Diagnosis
• Mis-Diagnosis
• Labs not ordered
• Treatment
• Wrong medication prescribed
• Perforation during IUD insertion

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Clinical PI Examples

• Lab Issues
• Patient given wrong persons test results
• Lab tests ordered, but never done
• Results never come back from outside lab
• Controlled Substances
• Stolen prescription pads / forged prescriptions
• Patient seeing multiple providers / pharmacies to
  obtain controlled substances

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Clinical PI Examples

• Chart Documentation
• Illegible handwriting
• Provider seeing patient without chart
• Phone/ Communication
• Provider never receives patient message
• Language and cultural barriers

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Clinical PI Case Study

• Follow-Up for Abnormal Labs
• F Identified problem through incident tracking.
  
• O Team included Medical Director, Nurse
  Coordinator, Medical Assistant, Lab Tech, staff
  person receiving mail / fax / delivery of lab
  results.
• C Baseline data collected via lab testing log, 3
  week period reviewed.
• U Problem areas included use of multiple outside
  labs, high volume, part-time clinicians, no clear
  person in charge of process.
• S Identified responsible person to track all
  abnormal labs. Benchmark set at 100 follow-up
  rate within 24 hours of notification.

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Clinical PI Case Study

• Follow-Up for Abnormal Labs
• P Plan thoroughly developed and outlined by team.
• D Implemented for three providers
• S Data collected 24-hour follow-up achieved for
  95 of cases. Not at benchmark repeat cycle.
• A Benchmark achieved!! Implemented changes for
  all providers.

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Resources

• NACHC
• www.nachc.org
• BPHC
• www.bphc.hrsa.gov
• JCAHO
• www.jcaho.org
• Institute for Healthcare Improvement
• www.ihi.org
• Your States Primary Care Association/Organization
  
• Contact us with questions
• (Trudy or Molly, Shoreline Health Solutions)
• info_at_shsconsulting.net or [phone]