Rapid Cycle Improvement Model Applied To Chlamydial Screening in Teens
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Transcript of Rapid Cycle Improvement Model Applied To Chlamydial Screening in Teens
Rapid Cycle Improvement Model Applied To Chlamydial Screening in Teens
A Partnership Between:Kaiser Permanente Northern California
& University of California, San Francisco
Mary-Ann Shafer, MDDivision of Adolescent Medicine
UCSF
Supported by the Agency for Health Care Research and Quality& the Centers for Disease Control and Prevention
ObjectivesObjectives
• Increase chlamydial (CT) screening of sexually active teen girls to meet HEDIS guidelines
• Develop, implement and evaluate a systems-based intervention that capitalizes on existing clinic resources while addressing barriers to CT screening using a rapid cycle approach
BackgroundBackgroundFacts About Facts About Chlamydia trachomatis (CT)Chlamydia trachomatis (CT)
• CT-most common reportable STI in teens
• Most asymptomatic-in males and females
• NAATs- 90-95% sens & spec feasible
• National Guidelines annual CT screen (e.g. CDC, USPSTF, AAP, ACOG, AMA)
• Only 25% of eligible population being screened
JAMA December 11, 2002
Learning ObjectivesLearning Objectives
• Review the development, implementation and evaluation of a systems-based rapid cycle clinical improvement intervention (CPI) to increase CT screening
• Discuss the application of the CPI model to different clinical settings including identifying and overcoming barriers to success
Rapid Cycle Rapid Cycle Applied To CT Applied To CT ScreenScreen• Recruit teamRecruit team• Problem solve at Problem solve at monthly monthly meetingsmeetings• Apply solutions Apply solutions && assess each assess each monthmonth• Repeat, sustainRepeat, sustain
Time in months
% C
han
ge in
STD
Scre
en
ing
Rate
S t a t u s Q u o
Rapid CycleRapid CycleChangesChanges
Step 1: Step 1: • Set GoalSet Goal• Define measureDefine measure• Identify barrier(s)Identify barrier(s)• Decide solutionDecide solution• Try it outTry it out
Time in months
% C
han
ge in
STD
Scre
en
ing
Rate
S t a t u s Q u o
Rapid CycleRapid CycleChangesChanges
Step 2Step 2• Assess trialAssess trial• Identify next barriersIdentify next barriers• Decide solutionDecide solution• Try it outTry it out
Time in months
% C
han
ge in
STD
Scre
en
ing
Rate
S t a t u s Q u o
Rapid CycleRapid CycleChangesChanges
Step 3Step 3• Assess trialAssess trial• Identify barriersIdentify barriers• Decide solutionDecide solution• Try it outTry it out• Repeat “cycles”Repeat “cycles”• Sustain gainsSustain gains
Time in months
% C
han
ge in
STD
Scre
en
ing
Rate
S t a t u s Q u o
Rapid CycleRapid CycleChangesChanges
Setting for Rapid Cycle ApplicationSetting for Rapid Cycle Application
Setting
Large HMO in Northern California: KP
• 10 pediatric clinics randomly assigned: 5-well care intervention and 5 control groups
• 2 of 5 intervention clinics target both well and urgent care visits
Methods
Urgent-Care Visit
• Same/next day visit
• Sick/non-ER visit
• 10 minute visit
• Same physical setting as WCV
• Same providers & staff as WCV
KP Pediatric Setting cont.
Well-Care Visit
• Appointment required
• Physical exam (every 2-3 yrs)
• 20 minute visit
Engage
Team Building
Re-Design Clinical Practice
Sustain the Gain
Clinical Practice Improvement Model
Clinical Practice Improvement Model
Engage
Team Building
Re-Design Clinical Practice
Sustain the Gain
•Leadership
•Best practices
•Define gap
•Raise Awareness
Engage
Team Building
Re-Design Clinical Practice
Sustain the Gain
•ACTeam•Skill building•Tool Kit
Clinical Practice Improvement Model
Engage
Team Building
Re-Design Clinical Practice
Sustain the Gain
•Customize•Measure success
Clinical Practice Improvement Model
Engage
Team Building
Re-Design Clinical Practice
Sustain the Gain
•Monitor performance•Time series analysis•Continuous improvement
Clinical Practice Improvement Model
Urines To Lab
MD/NPVISIT
RoomPatient
MA refrigerates FVUs A enters teen name, confidential # in clinic log book LRunner takes FVU to lab
MD/NP obtains sex hx
If sexually active, MD completes CT lab slip WWWrites confid. # on chart
MA collects FVU on all 14-18 yo F TTeen takes FVU sample to exam room
CueCharts
ID eligible teensC
Charts are stamped with cue
Follow-Up
RN contacts CT + teen: confid. #
Teen comes to clinic for Rx
RN enters Rx in STD log book
Site Specific Flow Chart
1. Cue Charts
IIdentify eligible (target) population (14-18 y teens) Charts stamped with cue
(Y2P!)C
2. Room Patient
MMA collects FVU on all 14-18 yo
TTeen takes FVU sample to exam room
a
C
3. VISIT
CMD/ NP obtains sexual hx IIf sexually active, MD completes CT lab slip
WWrites confidential phone number on chart
C
4. Urines to Lab
CMA refrigerates FVUs MA enters teen name,
confidential phone number in log book
LRunner takes FVU to lab
C
5. Follow-up
RN contacts CT + teen: confidential phone number
Teen comes to clinic for Rx
RN enters Rx into STD log book
C
Clinician’s Top Barriers to CT Screening in Primary & Urgent Care Settings
1. CONFIDENTIALITY: How separate parent?
2. TEEN SEX HX: How do I ask these things?
3. PRIORITIES: How competes in urgent care?
4. JOB DESCRIPTION: Is this part of my job?
5. PAYMENT: Who’s responsible?
6. POSITIVE CT RESULT: What do I do now?
Confidentiality Universal urine collection
Teen’s sexual history Teen-friendly rooming policy
Site Teen Health Champion
Anonymous chart reviews
Priorities for limited time Re-think visit priorities
Payment – copays Waived to protect teens small price to pay!
Positives tests FU protocol in place
Key Barriers Sample Solutions
RESULTS Female CT Screening Rates*Pediatric Well-Care Visits (14-18 yo)
*Chlamydia Screening Rate = #CT Tests/(#Well Care Visits *Sexual Activity Rate
0%
20%
40%
60%
80%
Pre-Test 1-3 4-6 7-9 10-12 13-15 16-18
% o
f Sex
ually
Act
ive
Fem
ales
Scr
eene
d
ExperimentalControl
Intervention Time Period in Months
RESULTS: Female CT Screening Rate in Urgent Care Pilot Sites
0
10
20
30
40
50
60
70
2000 2001 2002 2003
Year Clinic AClinic B
% S
A F
emal
es
Scre
ened
for C
T
A
A
A
B
B
B
Results of Intervention Evaluation
• Dramatic improvement in well & urgent clinics
• Sustainable & cost-effective
• Clinic differences in approachrate of improvement varies
• One solution does not fit all even within HMO
Implications
• Rapid cycle quick, customized & sustained
• Effective in different settings- well, urgent care & may be applied as a quality assurance tool
• Capitalizes upon existing resources & staff
• Small changes LARGE effects
• Gives chronically over-worked staff sense of importance, success & control over workplace