Transcript Slide 1
Eating the QI Elephant….
An example from New Hampshire… Lea R. Ayers LaFave, PhD, RN Community Health Institute/JSI Washington, DC September 16, 2010
The Charge: Provide insight into AIM statement development
Broad Concept for QI Develop an AIM Statement The Project – What we did… What happened….
• • • •
AIM Statement Development: Dimensions
Influence
– Is the problem workable?
– Do we have control over the element?
– Can a solution by implemented by the team?
Focus
– Internal or external?
Issue
– Target
operational
or strategic issues
Measurement
– Process measures more operational – Collected as work is performed or actions taken Benefits: early success/skill development
AIM Statement Development: Challenges
• Clear understanding of a problem – May be evolving – May be complex • Fine focus on an issue that can be – influenced – measured – affected within a finite time period • Clear linkage to more global aims
Caring Community Network of the Twin Rivers, NH
Old Mill Town Central NH
Background
• • •
Purpose of CCNTR
– To promote individual and environmental health as a fundamental requirement for healthy communities – Includes FQHC
Population:
– High poverty level rural community with all associated morbidities
Patterns:
– Reaction rather than prevention culture (chronic disease, substance abuse, emergencies) – Many providers don’t live in the community – Angry parents notified of student w/High BMI • why didn’t MD say anything?
– Lack of coordination/communication between PCPs and School Nurse about childrens’ healthy weights – Providers uncomfortable raising the issue • Healthy eating/active living not routinely discussed
2007-2008 Age/Gender Specific Body-Mass-Index (BMI) Percentile for Franklin School District K-4th Grade (n=496)
60% 50% 40% 30% 20% 10% 0% St udent s ( n=496) HEAL Goal* Healt hy Weight 0.48
Over weight 0.22
BMI Percentile Risk Rating
Obese 0.29
0.05
The Problem
• Annual well-child visits to health care professionals should include measurement of BMI to determine weight status (American Pediatrics Committee on Nutrition, 2003) • CCNTR PCPs rely on external websites to calculate BMI, then adjust the assessment tool to identify BMI risk rating. • If exam rooms lack internet access, BMI calculation will not be computed and interpreted to the patient with a discussion of behavioral strategies for patients or families of overweight children.
PLAN
Getting Started
• • • •
Getting Started Assemble the Team
Examine the Current Approach Identify Potential Solutions – Focus on Primary Care Setting and how weight related risk and behavioral assessment is being delivered to youth – Run report at 4 local primary care practices of children ages 2-19 with a well-child visit in 2007 fiscal year with a documented BMI or BMI percentile •
BMI documentation rates – wide variation - 7/1/07 6/30/08 (12.6-90%)
Team
• Community Health Center, Educators, Hospital-based QI/IT
PLAN
• • • • Getting Started Assemble the Team
Examine the Current Approach
Identify Potential Solutions
Current Approach
• Local providers lack EMR capability to efficiently screen/document BMI risk during well child visits • Healthy eating/active living not routinely discussed during visits • Lack of uniform office flow, self-management of health behavior goal setting
PLAN
• • • • Getting Started Assemble the Team Examine the Current Approach
Identify Potential Solutions
Potential Solutions
• Install new technology – calculates and documents BMI risk-rating and weight-related health behaviors into EMR at well-child visits. • Clinical staff education – evidence on obesity as indicator for chronic disease risk • Strengthen motivational interviewing techniques • Establish referral protocols – to community-based education, treatment and consultation resources regarding health eating/active living • Emphasize fit with Chronic Care Model
Develop an Improvement Theory
• If providers have access to BMI data, information about best practices and support in approaching families about health-related issues, they will address them. • The team will improve health care provider access to timely BMI risk rating analysis through – redesign of clinical flow to assess behavior, – provide effective communication strategies and referrals, – interpret weight related health into diagnosis and treatment • Goal: All 4 Primary Care Practices documenting at least 65% of children’s BMI seen in the following year
AIM Statement:
To increase the percentage of youth (>2 <19 years old) receiving primary care preventive services who had an age and gender appropriate Body Mass Index (BMI) percentile documented in their medical record at least once in the past year to 65% by June 30 th , 2009
Discrete – Measurable – Timebound
Test the Theory for Improvement
Do
• Educated providers – BMI measures – community profile – available referral resources – research identifying weight-related health as an indicator for chronic disease risk • Identified EMR BMI risk rating tool and uploaded for prompt evaluation at time of visit • Promoted routine calculation of BMI risk rating at each clinical encounter as a
VITAL SIGN
Do
• Designated a “Wellness Champion” in clinic Test the Theory for Improvement • Reviewed evidence and recommendations for increasing assessment, prevention, treatment and clinical guidelines • Created diagram and educate medical staff on clinical office flow for weight-related health risk factor assessment
Do
Documented Self Management goal in EMR as a measurable health indicator Test the Theory for Improvement
Do
Identified locations suitable for outreach activities to distribute printed materials to community members
Test the Theory for Improvement
STUDY
Use Data to Study Results of the Test
• •
Standardize the Improvement
Establish Future Plans
ACT
Standardize: Continue to…
– educate and promote the importance of daily behaviors related to 5210 Healthy NH – foster collaboration between CCNTR and local PCPs about referral for local nutritional and physical activity resources – utilize QI tools in day-to-day activities – engage in broad community outreach – familiarize CCNTR staff with QI concepts, tools and methods with particular evidence on evidence-based interventions
• • Standardize the Improvement
Establish Future Plans
ACT
Future Plans:
– Disseminate obesity statistics, trends and health indicators to health care partners to further develop QI echoing community efforts – Expand QI efforts to other Healthy Eating Active Living (HEAL) sectors in the region • worksites & workplaces • schools • food & recreation industries • communities & municipalities
Facilitating Factors
• Clear organizational mission • Root cause analysis – Shared view of the problem • Access to data • Wellness Champions • Regular meetings • • Development of data-rich environment – Clear linkage of outcome to intervening processes
Clear, focused, discrete, time-bound, measurable AIM statement based on assessment
Building an Information-Rich Environment
Questions?
Thank you!
Lea Ayers LaFave, PhD, RN
MLC-3 Project Director Community Health Institute/JSI 501 South Street, 2nd Floor Bow, NH 03304 603.573.3335
The Kansas Road: From Concept to Action
Tatiana Lin, Senior Analyst Kansas Health Institute MLC-3 Open Forum Washington D.C. September 2010
Objectives
Demonstrate the process of developing an aim statement Demonstrate the process of moving from concept to planning to implementation to outcomes
Overview
Snapshot of the Kansas First (MCH) Collaborative Develop an aim statement I. Plan II. Do III. Study IV. Act Lessons learned
Snapshot of the Kansas First (MCH) Collaborative
Map of the MLC-3 MCH Collaborative Teams
Source: U.S. Census Bureau, Census 2000
Introducing the Team Northeast Corner Subregion
The Northeast Corner Subregion Shawnee County Health Agency Jefferson County Health Department MLC-3 Team Composition: 9 members (e.g. pregnancy-testing clinics, STD clinics, WIC clinics) Targeted Programs: Title X Maternal Child Health Block Grant; Title X Family Planning/Pregnancy Testing; Women’s Infant and Children (WIC); SCHA Sexually Transmitted Disease; and SCHA-CHC M&I Prenatal Care
Develop an Aim Statement
Progression of the Aim Statement
Step 1: Learning about the issue Focusing Statement Step 2: Looking ahead Step 3: Narrowing focus Issue Statement Aim Statement
Step 1. Learning about the Issue Focusing Statement
a. What is the issue? Late entry into prenatal care b. What is the magnitude of the problem?
Know your data: Prenatal care by trimester: 1 st trimester: 51% 2 nd trimester: 47% 3 rd trimester: 2% Population of concern: 24-44 yrs (White, Non-Hispanic & Hispanic/Spanish speaking, not married, income <100%)
Step 2: Looking Ahead Issue Statement
a.
What is the main focus? Create your own question(s) • Does the group have complete control over the element?
Yes. The Northeast Subregion provides direct services to a significant number of women of childbearing age.
• What can we do for the patient(s)? Improve access? Improve outcomes? Provide better services? All three components • What are the potential causes? Existing referral system
Step 2. Looking Ahead Issue Statement Cont.
What are the benefits of addressing the issue?
• • Improved timeliness of prenatal care Improved birth outcomes
Step 3. Narrowing Focus – Aim Statement
a.
How do we focus our region’s resources to address this issue? Connect to services Improve access Improve birth outcomes
Initial Aim Statement
Achieve an annual average increase of pregnant women accessing services at the SCHA CHC M&I program in the first trimester by 2% per year by 2013 (61%).
:
Final Aim Statement
PMT Suggestions
1. Include a “target improvement date” 2. Include short-term measurable goals 4. Include the baseline rate, the target rate, and the percentage change 3. Include a “time component” such as “…to make a prenatal care appointment within the 14 th week of pregnancy”
Final Aim Statement
By Oct. 1, 2009, in four clinic programs at two local health departments, pregnant women not enrolled in prenatal care will consistently be given a current listing of community obstetricians , 90% of those with limited resources will receive staff assistance in making a prenatal intake appointment , and 95% of those intakes will be scheduled within 10 working days from the date of request.
Final Aim Statement Cont.
How will we know that a change is an improvement? Increased number of scheduled prenatal intake appointments Increased number of scheduled prenatal intake appointments within two-weeks of the initial request Increased number of women who entered prenatal care in the first trimester
PLAN
Current Approach
Current Approach Cont.
Limited number of prenatal intake appointments available each week Not all clinics provide a listing of area obstetricians Providing a listing of obstetricians does not guarantee the client will make a prenatal appointment Not all clinics consistently refer pregnant women to prenatal services Outdated information in regard to clinic hours and choices available for delivery sites Staff is challenged to complete referral paperwork Staff had an uncertain understanding of clients’ knowledge of the importance of early prenatal care
Do
Three PDSA Cycles
PDSA #1: Eliminate “cold handoff” referral Activities
:
Make intake appointment while the client is still on site – “Warm handoff”.
PDSA #2: Increase the number of available intake appointments Activities: Open/flex the M&I clinic intake appointment book to accommodate 2 – 5 more intakes per week.
PDSA #3: Identify common barriers to accessing prenatal care Activities: Conduct survey to identify common barriers to accessing prenatal care, methods and resources used by women to obtain prenatal care information.
Study
Three PDSA Cycles
PDSA #1: Eliminate “cold handoff” referral Results: Intake appointments were scheduled less than 2 weeks out.
Linking clients can be accomplished while clients are on site as long as appointment call is made during the clinics working hours. PDSA #2: Increase the number of available intake appointments Results: Increased the percentage of intake appointments kept within 2 weeks from date of request from 83% to 97%.
Need to consistently expand the number of intake appointments on a weekly basis; up to 2 – 5 appointments per week to accommodate demand.
Three PDSA Cycles Cont.
PDSA #3: Identify common barriers to accessing prenatal care Results: Two-thirds of the pregnant women at both clinics did not plan their pregnancies, making it harder for them to access prenatal care in a timely fashion after conception.
Need to continue analyzing the survey results
Results
ACT
Continue to expand the number of prenatal intake appointments.
Standardize the process to schedule prenatal intake appointments within ten working days.
Adopt reformatted intake registration form in both English and Spanish.
Closing Thoughts
Aim Statement Do’s 1. Base the aim statement on both data and organizational/regional needs Do your homework Learn about the issue Understand the level of your control Use aim statement to guide your work 2. State the aim statement clearly and use numerical, measurable goals Don’t 1.
2.
Wordsmith Spend too much time on the aim statement
Questions?
Contact Information Tatiana Lin Kansas Health Institute 212 8
th
Avenue, Suite 300 Topeka, KS 66614 PHONE: 785/233- 5443 EMAIL: [email protected]
Web site: www.khi.org
Kansas Health Institute
Information for policymakers. Health for Kansans.