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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?
2
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
8
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
.
“We think you may be suffering from information underload.”
YOU DID IT!
• Thank you•
