A Meaningful Quality Improvement Program that meets …...General Indicator Checklist 1-Hx =...

A Meaningful Quality Improvement Program that meets AAAHC Guidelines

Beth Brown MS, ANPConnie Hume-Rodman MD

ACHA May 30, 2012

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I’ll be happy to give you innovative thinking. What are the guidelines?

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Objectives

AAAHC criteria - 3 broad areas

How Oregon State’s program meets criteria QI study examples

Using EMR in our process

Peer Review program

Student Health ServicesLive well. Learn well. Be well.

AAAHC Compliance3 – Year Cycle

AAAHC GuidelinesBroad – Based Program

Clinical issues Cost of care Patient outcomes Administrative

Written Policy & Plan

Mission

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Volunteer Committee

Includes one physician

Goals and Objectives

Objectives 2010- 2013 Benchmark studiesNational clinical guidelinesAAAHC accreditation3 studies minimum

Goals 2011-2012

Complete outstanding studies Perform pertinent

studies & re-studies Continue prescription

writing error study

Goals 2011-2012Types of Studies

Patient outcome Cost of care Student learningAdministrativeNational

benchmark

Goals 2011-2012Peer Review

Clinician Physical Therapy Nursing SANE

Student Satisfaction Surveys-Internal/External-Focused

-Urgent Care

-LGBT

Sources of Studies

Peer Review Incident Reports Health & Safety

Committee

Studies from Individual Departments

Lab Pharmacy Physical TherapyMedical Records Clinicians Nursing Administration

Studies of Clinical Health Concerns

Prevalent diseases/injuries Concussion Depression

Internal benchmarking

Student Satisfaction Surveys

Student Learning Surveys Influenza Like IllnessNursing Advice LinePlan B Billing/Insurance

Link with risk management program Incident Reports Occupational Health

Annual Evaluation

Reporting

AAAHC Guidelines10 Elements of QI Study Reports

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Purpose and Description of Study Assessment of issue Reason for selecting Impact of topic

Goal of Study

What results are satisfactory? Guidelines or benchmarks used.

Study Methods

Data collected Data collection

process/tools

Findings

Data analysis Comparison of data against goal

Interventions and Recommendations

“As you can see we have thought carefully about ways of improving staff productivity.”

Evaluation and Conclusion

Goal reached?Re-study? Inform staff

AAAHC GuidelinesBenchmarking

Relevant Performance Measures

National Clinical Guidelines

Metabolic Syndrome Hypertension Concussion Depression

System for Data Collection and Analysis

ACHA Pap and STI Survey ACHA Clinical Benchmarking

Re-studies:• Ottawa Rules • Flu Shot Rates• Peak Flows for Asthma• Depression

Measuring Changes in PerformanceRe-studies and Peer Review

Using Local, State or National Standards

NCHA Survey- Gardasil vaccination rates

Incorporating Benchmarks Using EMR to improve quality

Centor Criteria Ottawa ankle rules Depression

-PHQ-9 Concussion

-SCAT 2 Animal Bite Reporting

Reporting Benchmark Results

Annual Report Shared Drive Department Meetings

-ACHA Benchmarks

“First, I want to give you an overview of what I will tell you over and over again during the entire presentation.”

AAAHC Accreditation Requirements

Peer Review Purpose

FEEDBACK

Individual

Supervisors

Collective Practice

Procedure

Quarterly

Fall & Spring-General-Diagnosis

Winter-Screening

Process

Random assignment

NP/PA

MD/DO DO/MD

PA/NP

Forms

Comments

Then and

now…

Courtesy of OSU Archives P57:7675

Changes

Tabulating Data

Modifying forms

Using EMR

“Regime change is never easy, dear.”

Tabulating Data

General Indicator Checklist 1-Hx = Adequate history recorded.2-PE = Adequate physical exam recorded.3-Dx = Assessment and diagnosis supported by history/physical.4-Tx = Treatment plan consistent with assessment and diagnosis. 5a-ED = Appropriate pt education discussed and recorded…5b-Verb.Tx = Patient indicates or verbalizes understanding of treatment.6-Rx = Appropriate meds prescribed and recorded.7a- F/U Adv. = Follow up advice given and occurred if recommended.7b-Verb.F/U = Patient indicates or verbalizes understanding of when to

return8-Consult = Appropriate and timely consultation if indicated.9-Tests = Diagnostic and therapeutic procedures are clinically necessary.10-F/u tests = Timely follow up of findings/test results. 11-Med.List = Medication list was updated and confirmed. 12-Allergies = Allergies or NKDA noted on Allergy section.13a-Med.Hx = All significant problems noted on the Medical History.13b-Prob.List = All significant problems noted on the Problem List.14-Rev.Hx = Past Medical History reviewed within the past year.15-Lock = Was chart note locked within 2 working days of visit?

Modifying forms

Separate Screening & General Indicators

Incorporate AAAHC indicators

Edit Indicator Checklist

Alcohol (Audit-C)

Depression

(PHQ-9)

Tobacco

BMI > 30

Screening Peer Review

Checklist

Using EMR

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“We think you may be suffering from information underload.”

YOU DID IT!

• Thank you•

beth.brown@oregonstate.educonnie.hume-rodman@oregonstate.edu

linda.reid@oregonstate.edu

Oregon State University in