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Transcript of Linda Juszczak, Interim Executive Director – NASBHC Tiffany A. Clarke, Program Associate –...
Linda Juszczak, Interim Executive Director – Linda Juszczak, Interim Executive Director – NASBHCNASBHC
Tiffany A. Clarke, Program Associate – NASBHCTiffany A. Clarke, Program Associate – NASBHC
September 21, 2008September 21, 2008
Quality Improvement in SBHCs
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Objectives Define terms and processes related to quality Review standards of care for children and
adolescents Review national quality improvement
initiatives related to children and adolescents Review standards of care in school health Identify measures of quality in school health Develop a strong comfort level as a trainer with
this content
3
The Components of Quality
How to measure?What to measure?Standards: What is the grade or level
of quality?
4
Definitions Quality of care is the degree to which health
services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (Institute of Medicine, 1990).
Quality assessment is the act of measuring quality of care, of detecting problems of quality, or of finding examples of good performance.
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Definitions
Quality assurance applies to an entire cycle of assessment which extends beyond problem identification, to verification of the problem, identification of what is correctable, initiation of interventions, improvements, and continual review to assure that identified problems have been adequately corrected and that no further problems have been engendered in the process.
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Definitions
Quality Improvement seeks to improve performance not just areas of unacceptable care. Quality improvement focuses on the processes of health care delivery and use of statistical approaches designed to reduce variations in those processes. (CQI, TQI)
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Evidence Based Decision Evidence Based Decision MakingMaking
Care should be based on:– the best available scientific knowledge and– should not vary illogically from clinician to
clinician or from place to place. Institute of Medicine ( IOM, 2006)
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The Process of Quality Improvement
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Methods: Quality by Inspection Theory of bad apples Find the bad apples and remove them Implies or establishes a threshold for
acceptability People are the cause of troubles Mortality data are used
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Methods: Theory of Continuous Improvement Problem is rarely related to the people but to the
process or the job design, failure of leadership, or unclear purpose
Need to understand and revise the production process
Use a variety of measures
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Methods: PDSA Cycle and Fundamental Questions for Improvement What are you trying to accomplish?How do you know if change =
improvement?What changes will result in improvement?
Langley et al, The Improvement Guide, 1996
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State objective of the cycle
Make predictionsDevelop plan to carry out cycle (who, what, where, when.)
Carry out the test.Document the problems and unexpected observations.
Begin analysis of the data.
Complete the analysis of the data.
Compare data to predictions.
Summarize what was learned.
What changes are to be made?
What will be the next cycle?
PDSA Cycle
Act Plan
DoStudy
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Repeated Use of the Cycle
A PS D
A PS DA PS D
D SP A
HunchesTheories
Ideas
ChangesThat Result
in Improvement
DATA
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PDSA Cycle Group Activity
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What Do You Measure? Structural Measures - the physical, financial and
organizational properties in which care is provided
Process measures - what is actually done in giving and receiving care and whether what is now known as “good” medical care has been applied
Outcome Measures - the effects of care on health status, knowledge, behavior and patient satisfaction
(Donabedian, 1966,1988,1992)
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Examples of Measures : Structural Staff credentials and training Physical environment Policy and procedures Supervisory practices
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Examples of Measures
Tests, treatment and clinical strategies in use
Comparison to a standard
Protocols
Total quality management methodologies
Focus on process through use of tools such as: process flow diagrams, cause& effect diagrams
Process Measures
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Examples of Measures: Outcomes
MorbidityMortalityPatient KnowledgePatient Satisfaction
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Joint Commission How care is delivered not prescriptive on
content of care - encourage best practice and innovation
Addresses level of performance for activities that affect the quality of care
Evaluates based on a set of standards of care, have to be in compliance with applicable standards AND intent of the standards
Analyze and evaluate the systems that drive operations and procedures
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Joint Commission Focus on activities with high volume, a degree
of risk and that tend to produce problems for staff or patients, and/or are costly
Need to establish a threshold for evaluation Frequency of data collection and review is
based on the significance of the event and the extent to which data reflects improvement
Can compare to other organization to improve performance (Benchmarking)
http://www.jcaho.org/standards
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Joint Commission - Standards
Patient focused functions– Patient rights and organizational ethics– Assessment of patients– Education– Continuum of care– Linguistically and culturally appropriate care
Organizational focused functionsStructures with functions
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Some “Hot” Areas –Joint Commission
Environment of care - is space equipped to provide care
Patient education activities (food-drug-drug/drug interactions, anticipatory guidance)
Medication management to reduce error Patient outcomes- vigorous analysis of practice Documentation in medical record Patient safety (new 7/01 now majority of
standards)
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Joint Commission - Improving Organizational Performance
Data are systematically aggregated and analyzed on an ongoing basis
Improved performance is achieved and sustained.
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Joint Commission
Beginning January 1, 2006, on-site surveys for accredited ambulatory care organizations and office-based surgery practices will be unannounced.
NP and PA credentialing process is becoming increasingly important
HEDIS 2009HEDIS 2009Weight assessment and counseling for
nutrition and physical activity for childrenChildhood immunizationChlamydia screening Appropriate testing for children with
pharyngitisAppropriate treatment for children with upper
respiratory infectionFollow up care for children prescribed with
ADHD medication
HEDIS 2009HEDIS 2009Children with chronic conditionsChildren and adolescent access to primary
care practitionersUse of appropriate medications for people
with asthmaFollow up after hospitalization for mental
illnessMedical assistance with smoking cessationAnnual dental visit
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Chart Reviews
How many?- < 30 visits do 100%, 30- <600 do 10%, > 600 do 5%
Need to be done to monitor medical and behavioral health record compliance- NCQA, Joint Commission, Insurance companies
Do focused reviews at the same time- CQI Tool or others
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What else do you need to do?
A person on staff is responsible for CQI Monitor the environment of care Written policies and procedures in place Written scope of care Patient satisfaction measured periodically Regular tracking of key variables to monitor
operations: no shows, cancellations, new to revisit ratio, apt to walk in ratio.
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Discussion
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Selecting a Standard of Care
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Guidelines for Review
US Preventive Services Task Force
Bright Futures GAPS
American Academy of Family Physicians
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Standards of Care : Themes
ComprehensivePeriodicEmphasis on prevention and educationCertain conditions/issues appear over
and over
33
Considerations In Guideline Selection
Age of your patient populationCharacteristics of your clinical practicePracticality of implementing in your
practiceAre there tools that can be used
effectively?Are there systems in place to document
and measure quality?
34
Quality Improvement Initiatives Related To Children And Adolescents
35
An Emerging National Agenda
Crossing the Quality Chasm (IOM, 2001)National Health Care Quality Report
(IOM, 2001)National Academy of Science call for
system of rewards based on performance ( NY Times, October 31st, 2002)
36
FACCT
(The Foundation for Accountability- Closed)
Dedicated to helping consumers have information they need to make better decisions about their health care. Formulates measures that consumers find relevant and easy to understand.
Child and Adolescent Health Measurement Initiative (CAHMI) - measure development– Young Adult Health Care Survey– Living with Illness– Promoting Healthy Development
Measures tested, submitted to HEDIS, used for plan QI, consumer information development, and research studies
37
Child and Adolescent Health Measurement Initiative (CAHMI) - Young Adult Health Care Survey (YAHCS)
Measures not just receiving care but the quality of care that adolescents receive for accountability purposes
Collaboration between NCQA, AAP, Children Now!,CDC, AHRQ, etc
Focus is on preventive care and align with national recommendations
Adolescents’ asked directly about the care they received
38
CAHMI - YAHCS
Adolescent Preventive Care (14-18 year olds) 56 questions
– Health care use– Privacy– Health and safety– Health information– Health care in the last 12 months– Your health – Demographics
Reliable and valid
http://dch.ohsuhealth.com/index.cfm?pageid=451§ionID=133&open=148
39
Consumer Assessment of Health Plan Survey (CAHPS)
Instrument in development that is intended to capture information about the experience and satisfaction adolescents’ report about basic aspects of care such as access and communication with providers.
Shares 20 items with YAHC Parents complete survey first then have
adolescents complete
https://www.cahps.ahrq.gov/default.asp
40
NICHQ: National Initiative for Child Health Quality
An action-oriented organization dedicated solely to improving the quality of health care provided to children.
Mission is to eliminate the gap between what is and what can be in health care for all children.
http://www.nichq.org
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NICHQ: National Initiative for Child Health Quality
AsthmaADHDChildren with special healthcare needsChildren in foster carePreventive careCultural competencyObesity
http://www.nichq.org
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2005 National Health Care Disparities 2005 National Health Care Disparities ReportsReports
Proportion of children whose parents report getting advice on physical activity is lower among poor and near poor children.
Childhood asthma admission rates are highest among black children
Many racial and ethnic minorities and persons of lower socioeconomic position are less likely to receive childhood immunizations
43
Issues Influencing Mental Issues Influencing Mental Health and CQIHealth and CQI
Limited evidence base and variations in care especially for children
Diversity of providersCharacteristics that distinguish mental
health from general health careCharacteristics of SBHC practiceChartingLess well developed infrastructure for
quality measurement
44
Organizations And Initiatives Organizations And Initiatives Conducting Systematic Evidence Conducting Systematic Evidence Reviews Related To Mental HealthReviews Related To Mental Health
Cochrane Group (developmental, psychosocial and learning problems)
USPSTF (suicide risk)National Registry of Evidence Based
Programs and Practice (brand name programs for prevention, CBT, multisystemic therapy)
Agency for Healthcare Research and Quality (AHRQ) - ADHD
45
Organizations and Initiatives Organizations and Initiatives Conducting Systematic Evidence Conducting Systematic Evidence ReviewsReviews
DOJ Federal Collaboration on What Works (prevention, intervention, treatment for juvenile justice, drug and ETOH)
Professional Associations
46
How Organizations Respond To Problems And Opportunities To Improve
Pathological: hide information, shoot the messenger, cover failures, crush new ideas
Bureaucratic: ignore information, tolerates messengers, promotes self as just and merciful, new ideas= problems
Generative: information is sought, messengers are trained, failures lead to inquiry , new ideas are welcomed
(Westrum,2004)
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The Learning Organization“…organizations where people continually
expand their capacity to create the results they desire, where new and expansive patterns of thinking are nurtured, where collective aspiration is set free, and where people are continually learning to see the whole together.”(Senge,1990)
48
The Learning OrganizationThere is a process of self examination and
continuous improvementOpenness and collaboration (patient
centered care)The best have the capacity to learn, adapt
and improve the fastest
49
Patient centered careOpenness drives improvementWell being of patients is paramountPeople should be able to learn anything
that affects their lives
50
Why be transparent?Leads to greater improvementInvolves parents and usersIncludes a view of why problems exist that
you would not have considered beforeThere is by in from all involved to
improve
51
What needs to happen in order to be transparent
Commitment to changeCreation of a culture of transparency
– Leadership– Re train staff– Regular reporting mechanism– Project level data – it is not about the
individual– Opportunities to practice being transparent
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RisksThe blame gameFear users will stop using the serviceFears regarding loss of position -status,
jobs etc
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Recommendations from NASBHC: Share your improvement data
Academic Success: with the schoolProductivity: with stakeholdersCQI Tool: with insurers and employers…now with users and families.
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Learning more about a culture of transparency
The Bell Curve, Atul Gawande (2004) http://www.newyorker.com/fact/content/?041206fa_fact
When Things Go Wrong (Harvard teaching institutions) http://www.ihi.org/NR/rdonlyres/A4CE6C77-F65C-4F34-B323-20AA4E41DC79/0/RespondingAdverseEvents.pdf
Pursuing Perfection- Cincinnati Children's
http://www.cincinnatichildrens.org/about/perfect/
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The patient has a right to transparency
“Nothing about me without me”Caregivers have no moral or legal
authority to withhold informationWithholding information is arrogant and
disrespectfulNot knowing causes anger, resentment and
loss of trust
(Leape, Atlanta, IHI IMPACT Mtg May 2006)
57
Pay for Performance The goal of pay-for-performance programs
should be to align reimbursement with the practice of high quality, safe health care for all consumers.
Controversial Complicated Cost reduction vs incentives Becoming more widely implemented. Providers
in HMOs being paid based on their performance.
58
Standards of Care for SBHCs
Historical
– Funders
– StatesNASBHC (Principles, CQI Tool, MHPET,
Collaboratives, Productivity)
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BREAK
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Best practice in SBHCs:
Standards, Principles, Program Evaluation, and
Evaluation of Clinical Care
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Principles for SBHCs
Supports the school Responds to the community Focuses on the student Delivers comprehensive care Advances health promotion activities Implements effective systems Provides leadership in adolescent and child
health
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A Program Evaluation Tool for SBHCs The 7 principles and their goals Structures needed to implement the goals - the
physical and organizational properties of the environment
Processes to support the goals - what is done to achieve the desired outcome
Outcomes that can be attributed to a desirable performance - satisfaction, behavior,morbidity
63
Examples of Outcomes Reduced number of
students who leave school during the day due to illness
High parent satisfaction
Increased enrollment for and utilization of SBHC services
Patient perception that well-being has improved
Increased compliance rates as measured by follow-up visits completed, prescriptions filled, therapy attended, referrals completed etc.
64
Questions Regarding Measurement of Quality in SBHCs
Are the things we want to measure truly important to the health of students?
Do the measures identify good health and care?
Can clinical practice make an impact on these conditions?
Are the measures practical?Do they work in the field?
65
Mental Health Planning and Evaluation Template (MHPET)
34 indicator measure which evaluates eight dimensions related to providing mental health services in schools– Operations– Stakeholder involvement– Staff and training– Identification, referral and assessment– Service delivery– School coordination and collaboration– Community coordination and collaboration– Quality assessment and improvement
www.nasbhc.org
66
Evaluation of Clinical Services in SBHCs (CQI Tool)
Sentinel conditions as a marker of the quality of clinical care
The foundation is an annual risk assessment and biennial physical exam
Limited number of conditions allows for meaningful evaluation
Intent is for the tool to be flexible
67
The SBHC CQI Tool Six conditions per age group (choose one of two
mental health conditions) References to support the inclusion of the
condition and to use to improve performance Resources necessary to provide quality care
relative to that sentinel condition Markers of care for that condition Measurement of the markers on a scale of 1 to 5
with threshold at 3
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Sentinel Conditions for Elementary School (CQI Tool)
Annual risk assessment and physical exam Asthma Risk for Type 2 diabetes Poor School Performance Oral Health Mental health
– Depression
– Psychological trauma
69
Sentinel Conditions for Middle School and High School (CQI Tool)
Annual risk assessment and physical exam Asthma Risk for Type 2 diabetes Tobacco use Substance use Chlamydia screening Immunizations Poor School Performance Oral Health Mental health
– Depression
– Psychological trauma
70
SBHC CQI Tool
The toolData collection formsInstructionsResources/glossary/directoryGuide to sampling populations
http://www.nasbhc.org
CQI GlossaryCQI Glossary
72
Why Is Improving Practice a Problem?
The demand for services keeps you reacting to crises and acute care requests
Lack of administrative support (school and SBHC operations/budget)
Effect on productivity
73
Why Is Improving Practice a Problem?
ReimbursementLack of parental involvementForces the providers to address the “hard”
issuesSBHC needs the partnerships/referral
relationships to support providing preventative services
74
Why Does It Matter?
Consistent with a standard of care Realizes the potential of the SBHC model Valued by insurers, government, parents, the
community and students themselves (?) Focused on finding adolescents at risk or already
in trouble Staff satisfaction
75
Essential Elements for Successful Prevention in SBHCs (NASBHC)
A prevention mission A supportive environment for students A competent staff Collaborative partnerships for prevention Effective strategies Accountability
76
Factors Associated with Successful Adoption of Innovations: Organizational Adopters
Decentralized decision making Can identify, capture, share and integrate new
knowledge Receptive to change through strong leadership,
clear vision, good management and climate conducive to experimentation and risk taking
Effective data systems Ready for change
Greenhalgh et al 2004
77
NASBHCs Benchmarking Efforts
Compare yourself to other apples not oranges Document the SBHC experience for
improvement and advocacy Tools
– CQI ( revision in 2008)
– Productivity ( on web www.nasbhc.org)
– Cost ( in development, contact [email protected] if interested in participating in beta test)
– MH PET ( on web www.nasbhc.org)