Transcript Slide 1

Improving Cervical Cancer
Screening Rates
Nanette Brey Magnani, EdD
Consultant, National Quality Center
888-NQC-QI-TA,
NationalQualityCenter.org
[email protected], 508-875-0290 p/fax;
Funded by HRSA
HIV/AIDS Bureau
Agenda
I. Overview
A. Discussion Points with Project
Officers
B. Define Measures, Collect Data,
Validate Data, Report
C. Improving Care: Goal Setting,
Basics of QI Projects and PDSAs
D. Sustain the Gains
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Agenda cont’d
I.
II.
III.
IV.
Examples of GYN QI Interventions
Resources
Grantee Presentation
Contacts
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Discussion Points with Your Project Officers on HAB QI Initiative
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Definition of Performance Measure
Data collection strategy
Validation method
Rationale for Goal(s)
QI Project Selection Process, Causal Analysis
QI Project Plans
Updates on effectiveness of PDSAs
Follow up and monitoring strategies for sustaining gains
SHARE your success!!!
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A. Define Your Measures
•HRSA draft measure
Number of female clients who had Pap screen results
documented within the measurement year/number of
female clients who were 18 or older and were seen
within the measurement year.
•HIVQUAL measure
Number of female clients who had a Pap screen within
the 12-month review period/the number of female
clients who were seen twice within the 12-month
review period with at least one visit within the last 6
months
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B. Collect Data: Sources of Data
 CADR
 HIVQUAL reports
 CAREWare
 Practice Management Systems/EMR
 Billing data
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Example: CADR DATA
Pelvic exam and pap test are currently
bundled in the CADR. Discrete data for each
element is not available.
Example: Part A Grantee
50% completion rate for annual pelvic/pap
test, or 150 women with pelvic/pap test
Working assumption:
Use pelvic rate/pap test as your pap test rate.
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Example: HIVQUAL Reports
There are discrete data elements for GYN exams
and Pap tests.
Example:
Female clients in sample = 29
Pelvic performed 15= 51.7%
Pap test
15 = 100% (of 51.7%)
Abnormal result
2 = 13%
2nd Pap test or GYN referral made
2= 100%
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Example: CAREWare Report
Example: A Part C program – AIDS Resource
Center/Wisconsin compiled the following
information
Review period 9/13 – 9/30,07 at Milwaukee site
# of women with visits
# of women pap due
# received Pap
% of women who were due and rec’d
Pap
Improving Cervical Cancer Screening Rates
170
58
29
29/58 =
50%
National Quality Center (NQC)
Data Validation:
Is the data accurate?
Accuracy of data: Why?
• to get buy-in from your clinical team,
providers, Planning Council members, and
Quality Management Committees. They want
to know that the problem is real and the
extent.
• to understand where you are starting from in
order to measure the degree to which
interventions make a difference in achieving
your goal
Improving Cervical Cancer Screening Rates
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Data Validation – How To
• Random sample of charts, chart review,
compare results
www.randomizer.org
• QI Project: Scranton Temple Residency Program
in Scranton, PA
 Compared data between CAREWare, Charts, and new EMR
to ensure data accuracy
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Display and Distribute Data
Simple Tables
Bar Charts
Run Charts
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B.
Making Improvements:
Goal Setting
If historical data are available, compare for trends
as a basis for goal setting. For example,
Heartland Health Outreach, Chicago – primarily homeless
and refugee clients
Indicator
2001 2002
2003
Annual
Pap
76%
63%
71%
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2004
goal
75%
2004
2005
79%
79%
National Quality Center (NQC)
Goal setting cont’d.
Benchmark your results with national data.
National HIVQUAL Data
Top 10%
Top 25%
Median
Average
03
04
05
100%
84.3%
73.3%
99.1%
86.7%
70%
100%
87%
74.3%
70.6%
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B. Improving Care: Basics of QI Projects – Causal Analysis
Causal Analysis
Tools:
• Flow diagram
• Fishbone diagram
• Brainstorm
Improving Cervical Cancer Screening Rates
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Example: Clarify Current Problem
Flowchart Initial Process Through Sample Collection (Univ of Pittsburgh Medical
Center)
I. New Patient:
1st Visit
PCP visit
PCP documents need
for GYN exam @ next
visit
Pt. needs
GYN
exam/visit
Next appointment is
scheduled
yes
GYN exam completed
during PCP visit
no
Possible chart review in the
future & assessed again
II. Return Visit
Need for GYN
determined
via: chart
review, excel
no
Possible chart review in
the future & reassessed
yes
PCP
Appointment
visit kept
no
a. If patient cancelled,
reschedule appointment
b. If no show, check again
at next PCP visit
Improving Cervical Cancer Screening Rates
yes
GYN
testing
completed
yes
Test/s completed
and sent to lab
no
Determine reason: new OB,
GYN care elsewhere, PCP
not comfortable doing GYN
exam, or patient scheduled
for exam at a future
appointment
National Quality Center (NQC)
Example: Select the Process to Change
(Fishbone Diagram (Un. of Pittsburgh MC)
Procedure
Patients
Patients cancel
appointments
Pt menstruating
& unable to
complete exam
If RN doesn't
check, pt. May
not know of apt.
Pt refuses or is
reluctant to have gyn
exam
Pap, etc. done
elsewhere & no
reports sent to PACT
Some providers may
not prefer to do a gyn
exam/testing
MD available to do
pap, but staff
unavailable to assist
Staff
Documentation
is not
standardized
Cumbersome procedure for
identifying who needs a
pap/gyn
Identification at 12th
month apt. doesn't allow
for delays
Lack of systematic
tracking of
anniversary dates
Pt with lack of understanding
of importance of periodic
paps/gyn exams
Rushed during
routine HIV care
appointment, no time
for pap/gyn exam
Lack of patient
reminder/trigger system
Multiple patient clinics
with less time to review
records
Limited
Comprehensiveness of
Women's Health Care
Exam, with decreasing
percentage of women
having an annual pelvic
examination
Seating is limited
in the exam room
Supplies are not
easily accessible in
the exam room
No flow in
room set-up
Privacy issues
during gyn exam
Room set up is
unworkable for patients
and staff
Supplies
Place
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Example: Histogram
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From Data To Improvement: Linking performance data to
QI activities
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B. Making Improvements: Basics of QI Projects
and PDSAs
QI Project – Quality Improvement Project,
generally comprises several PDSAs
within several categories of change
PDSA – Plan, Do, Study, Act
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PDSA Cycle
Plan, Do, Study, Act
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Repeated Use of Cycle
PDSA Measures
A P
Changes That
Result in
Improvement
S D
Implementation of
change
Wide-scale tests of
change
A P
S D
Hunches
Theories
Ideas
Follow-up tests
Very small scale
test
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Example for PDSA Cycle
Female clients
receiving a pap
test during any
appointment if
they need it
A P
S D
A P
S D
Cycle 1E: Implement and
monitor result quarterly
Cycle 1D: Incorporate suggestions,
expand to third physician.
Cycle 1C: Continue with Dr. Z’s patients and
expand to NP J’s patients for third week.
Cycle 1B: Try out the second week with Dr. Z’s
patients incorporating suggestions from 1st week
Cycle 1A: Try out with Dr. Z’s patients the first week
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PDSA Cycle (cont.)
Improving Cervical Cancer Screening Rates
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C.
Sustain the Gains: On Going Problem Solving and
Monitoring
Example of QI Project Monitoring: Unity Health Care
• QI Project Teams at each site met monthly.
• Site-based Team Leaders met monthly ng to discuss
interventions, progress, and obstacles. This dialogue
contributed to improved outcomes.
• Each team measured the effectiveness of
interventions by keeping a log.
Improving Cervical Cancer Screening Rates
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Example: Measure GYN QI Project Results
Site
Initial Audit
Results
QI Project
Goals
Audit
Results
following
QI Project
Site 1
64%
80%
82%
18%
Site 2
64%
85%
85%
21%
Site 3
52%
85%
76%
24%
Site 4
36%
95%
82%
46%
Improving Cervical Cancer Screening Rates
Percentage
Improvement
National Quality Center (NQC)
C. Sustain the Gains: On Going Problem Solving and Monitoring
cont’d.
Example: Putting systems in place after the QI
Project. (Multiple grantees)
Monitoring by HIV Quality Committee
 Monthly data (EMR)
 Quarterly data (CAREWare)
 Annual monitoring (HIVQUAL software)
 Chart review
Improving Cervical Cancer Screening Rates
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Monitoring to Sustain the Gain
Example: Monitor Goal Achievement
Run Chart prepared by Medical Director for Solano
County Family Health Services for a presentation to
County Board of Supervisors and the County Public
Health Department’s QI Committee
• 2 sites: Fairfield and Vallejo
• Improvement strategies included
 Better reminder system
 Added female Nurse Practitioner
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Example: Continue Monitoring to Sustain the Gains
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Annual Pap Test/GYN rates:
Examples from HIVQUAL Database
A. Raise awareness of need
B.
C.
D.
E.
Patient education/incentives
System of care
Scheduling and keeping appointments
Most frequent interventions
Improving Cervical Cancer Screening Rates
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A. Raise awareness of Need
 Highlight last Pap Test (Community Health
Care, Davenport/Iowa..)
 Print out pap rates by physician (UMass
Medical Center…)
 Tickler system to signal need
 Notice in chart
 Add to template (St. Mary’s Family Practice,
GJ,CO)
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A. Raise Awareness cont’d
 Daily chart review to identify need for




scheduled patients (City of Portland/Positive Health…..
Nurses set goals for % of Pap tests completed
in a quarter (16th St.CHC, Milwaukee)
Include annual Pap test as a 5th vital sign,
signal for alert (Brockton Neigh. Health Center….)
Pap bulletin board
CAREWare to track who needs annual
GYN/Pap – (Philadelphia Fight-Jonathan Lax Treatment
Center)
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B. Patient Education /Incentives
• Targeted messages (Lynn CHC, MA,
ARC/W, Gurabo CHC)
• Targeted strategies on an individual basis
• Send letter signed by providers as a
reminder of appointment
• Contacted directly by case manager
• Pap and Pamper Bag (incl bath and body
splash from Bed and Bath; $20 gift card to
Target – INOVA)
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B. Patient Education/Incentives cont’d
• $20 gift card for women who are chronic
no shows for Pap appointments (Family
First, York,PA)
• General incentives (Lehigh Valley Hosp, Allentown,
PA)
• Annual GYN exam/Pap scheduled at
time of patient’s birthday (Univ of Illinois/College
of Medicine, Peoria)
• Explain data for abnormal Pap smears
(Lancaster Gen. Hosp/PA)
Improving Cervical Cancer Screening Rates
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C. System of Care Changes
• Perform Pap test if needed during any appt. (Unity Health
Care, 16th St.CHC, Heartland Health Outreach, ARC/W, City of
Portland/ Positive Health, Southside Health Association/Chicago,
Jordan Hospital/Access Program, Fletcher Allen/VT, East Boston
NHC)
• Add to intake (Catholic Charities Diocese of Fort
Worth,TX)
• Refer to female practitioner, obgyn (St. Joseph Medical
Center, Reading, PA; Concilio de Salud Integral de
Loiza/PR)
• Integrate into annual physical exam (Lynn CHC, MA)
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C. System of Care Changes cont’d
• Team approach to discussing multi-pronged
approach (Gurabo CHC/PR…)
• Offer gyn exams at clinic (new offering, Puerto Rico
CoNCRA)
• Improve documentation from external providers
(Southside Health Association, Chicago;Jordan Hosp/Access
Project/MA,Lancaster Gen.Hosp/PA)
• Women’s health initiative
(St. Mary’s Family Practice, Grand
Junction, Un of Pittsburgh Medical Center)
• Train NPs to do Pap Tests (Detroit Medical Center)
• Exam room decorated like a spa (INOVA)
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D. Scheduling and Keeping Appointments
• Schedule Pap appt. within 3 weeks of
identifying the need
• Schedule if needed
• Schedule at time of birthday as an annual
reminder to both female clients and staff
• Same day appointment (El Proyecto Del Barrio)
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D. Scheduling and Keeping
Appointments cont’d
• Reminder calls by HIV nurse, staff, or
bilingual outreach worker (Brockton NHC, Southside
Health Association)
• Letters from physicians and NPs
• Reminder letters/cards (Partnership Health Center,
Scranton Temple Residency Program)
• No show letters
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Most Frequent Interventions
31 Different Interventions
• Perform pap if needed during any scheduled
appointment - 19
• Reminder letters and calls – 10
• Patient education - 5
Improving Cervical Cancer Screening Rates
National Quality Center (NQC)
III. Resources
• www.nationalqualitycenter.org
• www.hivqual.org
• 2003, 2004, and 2005 National HIVQUAL Performance Data
Aggregate Report (July, 2006)
• http://hab.hrsa.gov/tools/draftforcomment.htm
(draft copy of performance measures)
Improving Cervical Cancer Screening Rates
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Resources cont’d
Tools
Handout
HAB QI Initiative: Cervical Cancer
Screening: Areas for Exploration with
Grantees
Improving Cervical Cancer Screening Rates
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Resources to Randomize the Random Sample
• “Measuring Clinical
Performance: A Guide for HIV
Health Care Providers”
(includes random number
tables)
• A useful website for the
generation of random
numbers is
www.randomizer.org
• Common spreadsheet
programs, such as MS Excel
Sampling Records
Improving
Cervical Cancer Screening Rates
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IV. Grantee Presentation
Christiana Care
Wilmington, Delaware
Presenters: Arlene Bincsik, RN, Director
HIV Program
Robin Bidwell, RNC, Performance
Improvement Manager
Mary Kay Steinhaus, NP
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V. Contacts
Christiana Care, Wilmington, Delaware
Robin Bidwell, RNC, Performance Improvement
Manager, [email protected]
302-255-1307
Arlene Bincsick, HIV Program Director
[email protected]
Mary Kay Steinhaus, NP
[email protected]
Improving Cervical Cancer Screening Rates
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contacts cont’d.
Web Ex Presentation Faculty
University of Pittsburgh Medical Center
Linda Despines, RN, QM Coordinator,
[email protected], 412-647-5475
St. Mary’s Family Practice, Grand Junction, CO
Lucy Graham, [email protected]
AIDS Resource Center/Wisconsin, Milwaukee
Sharon O’Dwyer, Sharon.O'[email protected]
Improving Cervical Cancer Screening Rates
National Quality Center (NQC)