Transcript Quality Improvement In SBHCs

Quality Improvement in SBHCs
Linda Juszczak, Interim Executive Director –
NASBHC
Tiffany A. Clarke, Program Associate – NASBHC
September 21, 2008
Objectives
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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
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The Components of Quality
 How
to measure?
 What to measure?
 Standards: What is the grade or level
of quality?
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Definitions
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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
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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
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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
Making
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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
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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
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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?
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Langley et al, The Improvement
Guide, 1996
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Act
What changes
are to be made?
What will be the
next cycle?
Study
 Complete the
analysis of the data.
 Compare data to
predictions.
 Summarize what was
learned.
Plan
State objective of the
cycle
Make predictions
Develop plan to carry
out cycle (who, what,
where, when.)
Do
Carry out the test.
Document the problems
and unexpected
observations.
Begin analysis of the
data.
PDSA Cycle
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Repeated Use of the Cycle
A P
S D
Hunches
Theories
Ideas
Changes
That Result
in
Improvement
A P
S D
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 PDSA
Cycle Group Activity
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What Do You Measure?
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Structural Measures - the physical, financial and
organizational properties in which care is
provided
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Process measures - what is actually done in
giving and receiving care and whether what is
now known as “good” medical care has been
applied
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Outcome Measures - the effects of care on health
status, knowledge, behavior and patient
satisfaction
(Donabedian, 1966,1988,1992) 15
Examples of Measures :
Structural
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Staff credentials and training
Physical environment
Policy and procedures
Supervisory practices
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Examples of Measures
Process Measures
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Tests, treatment and
clinical strategies in
use
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Total quality
management
methodologies
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Comparison to a
standard
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Protocols
Focus on process
through use of tools
such as: process flow
diagrams, cause&
effect diagrams
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Examples of Measures:
Outcomes
Morbidity
 Mortality
 Patient Knowledge
 Patient Satisfaction
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Joint Commission
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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
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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
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Patient focused functions
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Patient rights and organizational ethics
Assessment of patients
Education
Continuum of care
Linguistically and culturally appropriate care
Organizational focused functions
 Structures with functions
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Some “Hot” Areas –Joint
Commission
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Environment of care - is space equipped to
provide care
Patient education activities (food-drugdrug/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
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HEDIS 2009
Weight assessment and counseling for
nutrition and physical activity for children
 Childhood immunization
 Chlamydia screening
 Appropriate testing for children with
pharyngitis
 Appropriate treatment for children with
upper respiratory infection
 Follow up care for children prescribed
with ADHD medication
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HEDIS 2009
Children with chronic conditions
 Children and adolescent access to primary
care practitioners
 Use of appropriate medications for people
with asthma
 Follow up after hospitalization for mental
illness
 Medical assistance with smoking cessation
 Annual 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 complianceNCQA, 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?
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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
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US Preventive
Services Task Force
Bright Futures
GAPS
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American Academy
of Family
Physicians
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Standards of Care : Themes
Comprehensive
 Periodic
 Emphasis on prevention and education
 Certain conditions/issues appear over
and over
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Considerations In Guideline
Selection
Age of your patient population
 Characteristics of your clinical practice
 Practicality of implementing in your
practice
 Are there tools that can be used
effectively?
 Are there systems in place to document
and measure quality?
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Quality Improvement
Initiatives Related To
Children And Adolescents
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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)
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FACCT
(The Foundation for Accountability- Closed)
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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
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Child and Adolescent Health Measurement
Initiative (CAHMI) - Young Adult Health
Care Survey (YAHCS)
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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
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CAHMI - YAHCS
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Adolescent Preventive Care (14-18 year olds)
56 questions
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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&sectionID=133&open=148
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Consumer Assessment of
Health Plan Survey (CAHPS)
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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
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NICHQ: National Initiative for
Child Health Quality
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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
Asthma
 ADHD
 Children with special healthcare needs
 Children in foster care
 Preventive care
 Cultural competency
 Obesity
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http://www.nichq.org
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2005 National Health Care Disparities
Reports
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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
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Issues Influencing Mental
Health and CQI
Limited evidence base and variations in
care especially for children
 Diversity of providers
 Characteristics that distinguish mental
health from general health care
 Characteristics of SBHC practice
 Charting
 Less well developed infrastructure for
quality measurement
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Organizations And Initiatives
Conducting Systematic Evidence
Reviews 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
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Organizations and Initiatives
Conducting Systematic Evidence
Reviews
DOJ Federal Collaboration on What
Works (prevention, intervention, treatment
for juvenile justice, drug and ETOH)
 Professional Associations
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How Organizations Respond To
Problems And Opportunities To
Improve
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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
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“…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)
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The Learning Organization
There is a process of self examination and
continuous improvement
 Openness and collaboration (patient
centered care)
 The best have the capacity to learn, adapt
and improve the fastest
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Patient centered care
Openness drives improvement
 Well being of patients is paramount
 People should be able to learn anything
that affects their lives
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Why be transparent?
Leads to greater improvement
 Involves parents and users
 Includes a view of why problems exist that
you would not have considered before
 There is by in from all involved to improve
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What needs to happen in order
to be transparent
Commitment to change
 Creation of a culture of transparency
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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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Risks
The blame game
 Fear users will stop using the service
 Fears regarding loss of position -status,
jobs etc
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Recommendations from NASBHC:
Share your improvement data
Academic Success: with the school
 Productivity: with stakeholders
 CQI Tool: with insurers and employers
 …now with users and families.
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Learning more about a culture of
transparency
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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-F65C4F34-B32320AA4E41DC79/0/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 information
 Withholding information is arrogant and
disrespectful
 Not knowing causes anger, resentment and
loss of trust
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(Leape, Atlanta, IHI IMPACT Mtg May 2006)
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Pay for Performance
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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.
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Standards of Care for SBHCs
Historical
– Funders
– States
 NASBHC (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
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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
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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
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Examples of Outcomes
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Reduced number of
students who leave
school during the day
due to illness
High parent
satisfaction
Increased enrollment
for and utilization of
SBHC services
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Patient perception that
well-being has improved
Increased compliance
rates as measured by
follow-up visits
completed, prescriptions
filled, therapy attended,
referrals completed etc.
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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?
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Mental Health Planning and
Evaluation Template (MHPET)
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34 indicator measure which evaluates eight
dimensions related to providing mental health
services in schools
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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
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Evaluation of Clinical Services
in SBHCs (CQI Tool)
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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
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The SBHC CQI Tool
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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)
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Annual risk assessment and physical exam
Asthma
Risk for Type 2 diabetes
Poor School Performance
Oral Health
Mental health
– Depression
– Psychological trauma
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Sentinel Conditions for Middle
School and High School (CQI
Tool)Annual risk assessment and physical exam
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Asthma
Risk for Type 2 diabetes
Tobacco use
Substance use
Chlamydia screening
Immunizations
Poor School Performance
Oral Health
Mental health
– Depression
– Psychological trauma
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SBHC CQI Tool
The tool
 Data collection forms
 Instructions
 Resources/glossary/directory
 Guide to sampling populations
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http://www.nasbhc.org
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CQI Glossary
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
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Why Is Improving Practice a
Problem?
Reimbursement
 Lack of parental involvement
 Forces the providers to address the “hard”
issues
 SBHC needs the partnerships/referral
relationships to support providing
preventative services
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Why Does It Matter?
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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
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Essential Elements for Successful
Prevention in SBHCs (NASBHC)
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A prevention mission
A supportive environment for students
A competent staff
Collaborative partnerships for prevention
Effective strategies
Accountability
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Factors Associated with Successful
Adoption of Innovations:
Organizational Adopters
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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
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NASBHCs Benchmarking
Efforts
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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)
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