Sponsored by the National Association of Community Health Centers
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Sponsored by the Sponsored by the National Association of Community Health CentersNational Association of Community Health Centers
Presented By Shoreline Health Solutions, LLCPresented By Shoreline Health Solutions, LLC
Trudy Brown Ripin, MPHTrudy Brown Ripin, MPH President & FounderPresident & FounderMolly K. Gwisc, MPHMolly K. Gwisc, MPH AssociateAssociate
Implementing Quality Improvement Activities Implementing Quality Improvement Activities at Your Community Health Centerat Your Community Health Center
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Components of PI ProgramProactive / preventative
strategiesBefore something goes wrong
Peer Review Chart Completeness High Risk Procedures Patient Satisfaction
Reactive / responsive strategiesAfter 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 GoalsAnswer 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
Other’s 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 DataAnalyze 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 patient’s 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 AuditsEvaluates 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 AuditsAudit 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 SatisfactionWhy is Patient Satisfaction Important?
Customer Satisfaction
Measures Patient Care Quality
Demonstrates Commitment To Quality Care
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Patient Satisfaction SurveyCulturally, 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 AreasEnsure representative sample Maintain patient confidentialityTopic 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 StrategiesPatient 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 ProgramReview 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 CategoriesClinical TriageClinical EvaluationClinical TreatmentClinical Follow-UpClinical SupportMedicationLabMedical Emergency
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Non-Clinical Incident CategoriesCommunicationHazmat SpillViolent / Disruptive PatientTheftAccident / InjurySexual HarassmentBreach 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 TrackingTypes 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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ResourcesBureau of Primary Health Care (BPHC)
www.bphc.hrsa.gov
Your State’s Primary Care Association / Organizationwww.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 QuestionsNational Association of Community Health Centers (NACHC)
(301) 347-0400 [email protected]
NACHC Managed Growth Assistance Program (Pamela Byrnes, Director)
(860) 739-9224 [email protected]
Trudy Brown Ripin or Molly Gwisc from Shoreline Health Solutions
(860) 395-5630 [email protected] www.shsconsulting.net