Sponsored by the

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Implementing Quality Improvement Activities at
Your Community Health Center

• 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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Components of PI Program

• Proactive / preventative strategies
• Before something goes wrong
• Peer Review
• Chart Completeness
• High Risk Procedures
• Patient Satisfaction
• Reactive / responsive strategies
• After something goes wrong
• Patient Complaint Response
• Incident Follow-Up
• Sentinel Event Response

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Peer Review Program
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Peer Review Goals

• Answer Specific Clinical Quality Questions
• How well do we handle acute visits for otitis
  media?
• Are we addressing substance abuse and mental
  health needs in the context of routine clinical
  visits?
• Are we providing HIV counseling for patients on
  birth control?
• Compare Quality Indicators to External / Internal
  Data
• National or State benchmarks compare our care
  with other CHCs
• Internal historical data evaluates changes over
  time

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Peer Review Implementation

• Providers Review Random Sampling of Each Others
  Charts
• Peer Review Cycles Done Quarterly or Monthly
• Definition of Peer
• Standardized Audit Tool
• For each chart, each question is compliant,
  deficient, or not applicable
• General vs. Topic-Specific Audits
• Selecting Audit Criteria www.guidelines.gov
• Audit of Individual Visit, Past Year, Full Chart

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How to Use Your Data

• Analyze Individual Trends
• Measure Individual Provider Performance Over Time
• Compare Individual Results to Aggregate Data
• Analyze Clinical Practice Trends
• Are We Meeting Basic Quality Goals?
• How Are We Doing Compared with Last Year?
• Are We In Line With National Goals?
• Educate Provider Staff
• What Level Of Quality Can Realistically Be
  Achieved?
• What Specific Areas Of Care Can I Improve?

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Peer Review Data Response

• Individual Patient Follow-Up
• Provider Performance Review
• Develop Provider-Specific Action Plan if
  Appropriate
• Quality-Related Systems Changes
• Develop Systems-Level Quality Improvement
  Activities if Appropriate

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Chart Completeness Audits

• Protects patient safety
• Provides continuity of care
• Measures accuracy, completeness, and legibility
  of medical records
• Uses standardized tool

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Sample Chart Completeness Questions

• Is there an up to date problem list in the chart?
• Is there an up to date medication list in the
  chart?
• Are flow sheets current?
• Are any lab reports up to date, initialed and
  dated?
• Are all immunizations documented?
• Does each form have the patients name on it?
• Is there a signed consent to treat in the chart?
• Are all entries signed?
• Are drug allergies conspicuously documented?

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Chart Completeness Audits

• Evaluates chart documentation
• Conducted daily, weekly, or monthly
• Set goal for number of charts to review each
  audit
• Can be done by non-clinical staff
• Need immediate and systems-level response

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High Risk Procedure Audits

• Definition of high-risk procedure
• Risk of serious complications
• Examples include perforation infection
• Benefits of high-risk procedure audits
• Identifies individual concerns
• Identifies systemic concerns

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High Risk Procedure Audits

• Audit questions may include
• Was there excessive bleeding?
• Was there an infection?
• Was there perforation?
• Was appropriate follow up conducted and
  documented?

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Informed Consent for High Risk Procedure Audits

• All Patients Should Sign Before High Risk
  Procedure
• Understand Benefits Risks
• Be Informed Of Alternatives
• Good Clinical Care
• Liability Protection/ Risk Management

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Patient Satisfaction

• Why is Patient Satisfaction Important?
• Customer Satisfaction
• Measures Patient Care Quality
• Demonstrates Commitment To Quality Care

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Patient Satisfaction Survey

• Culturally, linguistically, and reading-level
  appropriate
• Typically annually
• Results aggregated overall and by service / site
• Present results to leadership and Board
• Initiate PI projects to address most significant
  issues
• Provide feedback to patients

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Survey Topic Areas

• Ensure representative sample
• Maintain patient confidentiality
• Topic Areas Include
• Appointments (Phone hold time Same-day for
  urgent needs Provider of Choice / PCP)
• Staff (Courteous, helpful, and respectful
  Ability to communicate well Confidentiality and
  privacy)
• Facilities (Clean and comfortable Feeling of
  safety inside and outside Clear signage)
• Wait Time (Waiting room, exam room, check-out
  area Information provided about wait time or if
  delays expected)

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Other Patient Satisfaction Strategies

• Patient suggestion/comment box
• Staff training on de-escalation techniques
• Ongoing consumer feedback
• How are we doing? cards
• Patient focus groups
• Board consumer member leadership
• Patient complaint response and tracking systems

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Patient Complaints
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Patient Complaint Response Program

• Document the complaint
• Standardized complaint form
• Who can complete form
• When to complete form, when in doubt, fill it
  out
• Where to place the completed form
• Immediately rectify problem
• Urgent medical need
• Dirty rest room
• Feedback to staff
• Feedback to patient

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Patient Complaint Response Program

• Review handling of individual complaint
• Handled with respect, efficiently, and
  effectively
• Patient seems to feel better
• Proper documentation
• Appropriate follow-up
• Identify complaint trends
• Frequent types of complaints
• Develop categories (may include phone issues,
  staff misconduct, wait time, accessibility of
  services, failure to follow up, and translation
  or cultural issues)
• Initiate PI project to respond to frequently
  occurring issues
• Report trends to leadership and Board

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Incident Response
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Clinical Incident Categories

• Clinical Triage
• Clinical Evaluation
• Clinical Treatment
• Clinical Follow-Up
• Clinical Support
• Medication
• Lab
• Medical Emergency

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Non-Clinical Incident Categories

• Communication
• Hazmat Spill
• Violent / Disruptive Patient
• Theft
• Accident / Injury
• Sexual Harassment
• Breach of Confidentiality

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Incident Response is the Same as Complaint
Response

• Complete Incident Report Form
• Include Person completing form, people
  involved, date, time, location, description,
  response, resolution
• Investigate What Happened
• Interview involved staff and patients
• Review medical records, phone message logs,
  appointment schedule
• Feedback to all involved patients, visitors,
  staff
• Immediate Response to Individual Incident

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Incident Response is the Same as Complaint
Response (cont)

• Identify Most Frequently Occurring Incidents
  (Trends)
• Report Trends to Leadership and Board
• Develop Systems-Level PI Response to Trends
• Staff training

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Incident Tracking

• Types of tracking systems
• Paper or electronic tracking systems
• Need to distinguish unresolved incidents
• Variables to track and trend
• Number of forms submitted overall
• Most frequent categories
• Changes over time

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Sentinel Event Response
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Sentinel Event Definition

• Incident that caused death or serious injury
  (physical or emotional)
• Near miss incident that COULD have caused death
  or serious injury, even though this time it
  turned out OK
• Does not include adverse outcome due to natural
  course of illness
• Not the fault of an individual, multiple system
  failures

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Examples of Sentinel Events

• Rape or sexual exploitation on-site
• Administering wrong medication
• Not following up on abnormal lab
• Dental extraction of wrong tooth
• Mis-diagnosis, missed diagnosis, delayed
  diagnosis
• Patient death immediately following a procedure

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Incident Versus Sentinel Event

• Sentinel event is a type of incident SEVERE
• Short-term response is the same as any incident
• Utilize same report form and reporting procedures
• Immediate response to individual incident
• Not looking at trends, looking at individual
  event
• Root cause analysis

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Root Cause Analysis

• Ask WHY X 5
• Team of 2 -3 people
• Complete RCA quickly
• Identify and correct systems failures
• Plan for human error
• Put backup systems in place

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Case Study Patient Suicide

• Document, investigate, respond, and report the
  event
• Identify root causes and system failures
• Poor communication
• Inconsistent scheduling
• Unclear task assignments
• Prevent recurrence

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Final Thoughts on Improving Quality

• Identify potential problems
• Peer review
• Chart completeness
• Procedure audits / informed consent
• Patient satisfaction program
• Respond when things do go wrong
• Patient complaints
• Incidents
• Sentinel Events
• Implement in stages, full implementation within 1
  year
• Develop a comprehensive program

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Resources

• Bureau of Primary Health Care (BPHC)
• www.bphc.hrsa.gov
• Your States Primary Care Association /
  Organization
• www.bphc.hrsa.gov/osnp/PCADirectory
• Joint Commission on Accreditation of Healthcare
  Organizations (JCAHO)
• www.jcaho.org
• Institute for Healthcare Improvement (IHI)
• www.ihi.org

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Contact Us With Questions

• National Association of Community Health Centers
  (NACHC)
• [phone] contact_at_nachc.com www.nachc.com
• NACHC Managed Growth Assistance Program (Pamela
  Byrnes, Director)
• [phone] pbyrnes_at_nachc.com
• Trudy Brown Ripin or Molly Gwisc from Shoreline
  Health Solutions
• [phone] info_at_shsconsulting.net www.shscon
  sulting.net