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Funded by HRSAHIV/AIDS Bureau
Application of Quality Improvement: Cervical Cancer Screening
Aug 25, 2008
Presenters: Lori De Lorenzo, MSN, RN
Nanette Brey Magnani, EdD, NQC Grantee: Christiana Care Health System
Robin Bidwell, RNC, Arlene Bincsick, HIV Program Director
National Quality Center (NQC)2
Agenda
1. Background on HABs Focus and Initiative2. Lessons from the Field
QI ProjectsExamples from Grantees
3. AddendumSpecific QI interventions (Ideas for Improvement)Fishbone diagram exampleResourcesContacts
National Quality Center (NQC)3
1. Focus on Quality
Ryan White Grantees have quality management legislative mandates
Focus on quality by HAB Internal External
Interest on quality initiatives in variety of areas
Cervical cancer screeningPatient show rates
Funded by HRSAHIV/AIDS Bureau
HAB QI Initiative: Cervical Cancer Screening
National Quality Center (NQC)5
What was the Initiative?
An opportunity for HAB to look at a specific issue and effect change through application of quality improvement
2007: Year of the PapBureau-wide quality improvement initiative that focused on improving cervical cancer screening rates
National Quality Center (NQC)6
What were the Goals?
Improve cervical cancer screening completion rates across programs
Raise awareness of PHS guidelines
Increase awareness of low completion rates Improve data being submitted to HAB
Increase capacity of providers to provide & document screening
Train POs to facilitate & discuss improvement activities
National Quality Center (NQC)7
Why Was it Undertaken?
PHS Guidelines related to cervical cancer are established & fairly straightforward
Change can make a differenceAbnormal Pap smears are more than 4 times higher in HIV-infected women HIV-infected women have a higher prevalence of HPV infection HIV-infected women are 5 times more likely to develop squamousintraepithelial lesions (SIL) Invasive cervical cancer is an AIDS defining illness
Data indicated this is an area where improvement is needed
CADR, GPRA, DCBP Client Level Data, HIVQUAL, NRC study
National Quality Center (NQC)8
What was Done?
Activities focused on 2 parallel tracksDataSystem of care
All focused on strategies to improve completion rates
National Quality Center (NQC)9
Data-Related Activities
All available data reviewedCADR, GPRA, DCBP Client Level Data, HIVQUAL, NRC study
Additional study conducted to further explore issues related to data collection
Hindering & facilitating factors
National Quality Center (NQC)10
System of Care Activities
Released NRC report on common system, cultural and social barriers
NQC conducted 2 TA calls on cervical cancer screening initiatives
Culled best practices from HIVQUAL grantees
Implemented training plan for POs to prepare them for discussion with grantees
PO Talking Points
AETC Workgroup created series of training materials & resources
National Quality Center (NQC)11
HIV Screening & Womens Health curriculumClinical Issues Training of Trainers Package
Slide sets with talking points on: Pap smears and pelvic exams HPV Common STDs
System Issues Technical Assistance Package
Slide set on using a fishbone diagramGuidebook on assessing and remedying barriers to cervical cancer screening
www.aidsetc.org
Womens Health & Wellness Workgroup
National Quality Center (NQC)12
2. Lessons From the Field
Scenario: Presentation of Aggregate Pap Test Data to HIV Quality Committee and providers.
Example: Annual Pap Test results: 18%; 42%...
Reaction:The data isnt correct.That doesnt reflect my percentages.Patients refuse and are always menstruating.
National Quality Center (NQC)13
What do you do?
Scenario 1. Team agrees data may not be accurate. Decides to do Data QI Project.
Scranton Temple Residency Program in Scranton, PA
Compared data between CAREWare, Charts, and new EMR to ensure data accuracy for reporting
Achieved >90% accuracy and maintained achievement
National Quality Center (NQC)14
What do you do?
Scenario 2: Team discusses results and concludes there is variability among providers. Decides to report data by provider.
National Quality Center (NQC)15
QI Intervention: Does this reflect a systems problem or a problem with individual provider processes?
National Quality Center (NQC)16
What do you do?
Scenario 3: The team agrees with the data and moves to do a Pap QI Project.
Christiana Care Health Services
National Quality Center (NQC)17
Baseline data: WHERE IS YOUR DOT?
Site TotalNumber of Patients
Numberof Women
% withDocumentedPAP results inMedicalRecords
Wilmington 800 320 42%
Smyrna 140 58 53%
Georgetown 260 67 57%
National Quality Center (NQC)18
What Are the Underlying Causes of Low Rates?
Brainstorm a list.
National Quality Center (NQC)19
Initial Interventions
Wilmington:Established a nested Womens Only Clinic at the Wilmington Hospital Annex to improve access to womens health services and overcome some of these barriers
Ryan White Part D staff were assigned to the project and included a nurse practitioner, a primary care nurse, a pharmacist, and a social worker
Smyrna and Georgetown:Coordinated TransportationProvided incentivesPart D staff attended appointments with patients to outside providers
National Quality Center (NQC)20
Results: Baseline and Today
0%10%20%30%40%50%60%70%80%90%
100%
Wilm Smy Ggtwn
National Quality Center (NQC)21
Follow Up of Abnormal Results
Nurse Practitioner certified to perform on site colposcopies has improved follow up of abnormal results at Wilmington site
0%
10%
20%
30%
40%
50%
60%
Wilm Smyrna Gtwn
National Quality Center (NQC)22
Results- Christian Care Health Services
The ONLY intervention that demonstrated SIGNIFICANT and SUSTAINABLE improvement was to include pelvic exams as part of routine office visit
National Quality Center (NQC)23
Quantitative and Qualitative Results Scranton Temple Residency Program
Baseline: 2005 13%Intervention 1: Proactive effort to schedule
women for annual Pap Tests 2006 56%2007 50%
Intervention2: Initiated a Womens Health Clinic on Wednesdays with Nurse Practitioner and a gift Spa bag with toiletries and other personal care items
National Quality Center (NQC)24
Results of Intervention 2
June 30, 2008116 Active women
3 refuse GYN care5 need to see GYN for care due to abn. Pap Test6 high risk issues (hospice/cancer care, life/chaos, pregnancy3 have received Pap Tests elsewhere; need doc.
63 of 99 remaining women current 36 of them currently need Pap Tests (2/3 of
whom STRP provides primary care)
National Quality Center (NQC)25
The Real Story
The real story for STRP is the return rate and how comfortable women are coming back for their annual visits. Sister Ruth says, Once they come in, they are sold! They receive a gift for doing the right thing which has been very well received. The women feel special for that one hour and cared for by the health center. One woman said, I dont think of this as a clinic; this is my family. The opportunity to reach women on issues of obesity, depression and anxiety has been tremendous. I could give you an example for everyone. We at STRP are providing care to those with HIV that treats the person as an individual with dignity and respect along with excellent medical care.
Mary Lawhon Triano, CRNP-C
National Quality Center (NQC)26
Most Frequent Interventions for Pap Improvement QI Projects HIVQUAL Database
31 Different Interventions System of Care:
Perform pap if needed during any scheduled appointment - 19
Scheduling and Keeping Appointments: Reminder letters and calls 10
Patient Education and Incentives 5Raise Awareness of Need
National Quality Center (NQC)27
Link Between Cervical Cancer Screening & Patient Show Rates
Cervical Cancer Screening Initiative is one example of HABs increasing involvement in QM/QI
Key issue in completing cervical cancer screens can be part of a larger issue related to retaining patients in care
National Quality Center (NQC)28
3. Addendum
Specific QI interventions (ideas for improvement) Fishbone diagram example Resources Contacts
National Quality Center (NQC)29
Specific QI Interventions from Grantees
National Quality Center (NQC)30
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 needNotice in chartAdd to template (St. Marys Family Practice, GJ,CO)
National Quality Center (NQC)31
A. Raise Awareness contd
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 boardCAREWare to track who needs annual GYN/Pap (Philadelphia Fight-Jonathan Lax Treatment Center)
National Quality Center (NQC)32
B. Patient Education/Incentives contd
$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 patients birthday (Univ of Illinois/College of Medicine, Peoria)
Explain data for abnormal Pap smears (Lancaster Gen. Hosp/PA)
National Quality Center (NQC)33
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, ob/gyn (St. Joseph Medical Center, Reading, PA; Concilio de Salud Integral de Loiza/PR)
Integrate into annual physical exam (Lynn CHC, MA)
National Quality Center (NQC)34
C. System of Care Changes contd
Team approach to discussing a 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)
Womens health initiative (St. Marys 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)
National Quality Center (NQC)35
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)
National Quality Center (NQC)36
D. Scheduling and Keeping Appointments
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
National Quality Center (NQC)37
Tools: Flow Diagram and Fishbone Analysis
Purpose of Flow Diagram: To determine steps in the process and to identify problems associated with particular steps. The analysis guides selection of improvement strategies.
Purpose of Fishbone Analysis: To determine underlying causes related to a problem. Once identified, causes are then prioritized. The analysis guides selection of improvement strategies.
National Quality Center (NQC)38
Example: Clarify Current Problem Flowchart Initial Process Through Sample Collection (Univ of Pittsburgh Medical Center)
yes
no
yes yes yes
no no no
Pt. needs GYN
exam/visit
PCP visit I. New Patient: 1st Visit
PCP documents need for GYN exam @ next
visit
Next appointment is scheduled
Possible chart review in the future & assessed again
Need for GYN determined via: chart review, excel
PCP Appointment
visit kept
GYN testing
completed
Possible chart review in the future & reassessed
a. If patient cancelled, reschedule appointmentb. If no show, check again at next PCP visit
Determine reason: new OB, GYN care elsewhere, PCP not comfortable doing GYN exam, or patient scheduled
for exam at a future appointment
GYN exam completed during PCP visit
II. Return Visit Test/s completed and sent to lab
National Quality Center (NQC)39
Example: Select the Process to Change (Fishbone Diagram (Univ. of Pittsburgh MC)
Limited Comprehensiveness of Women's Health Care
Exam, with decreasing percentage of women
having an annual pelvic examination
Patients
Patients cancel appointments
If RN doesn't check, pt. May not know of apt.
Pt menstruating & unable to complete exam
Pt refuses or is reluctant to have gyn exam
Pap, etc. done elsewhere & no reports sent to PACT
Pt with lack of understandingof importance of periodic paps/gyn exams
Procedure
Lack of patient reminder/trigger system
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
Multiple patient clinics with less time to review records
Documentation is not standardized
Staff
Rushed during routine HIV care appointment, no time
Some providers may not prefer to do a gyn
MD available to do pap, but staff unavailable to assist
Supplies
Supplies are not easily accessible in the exam room
Place
Seating is limited in the exam room
No flow in room set-up
Privacy issues during gyn exam
Room set up is unworkable for patients and staff
National Quality Center (NQC)40
Helpful Resources
Technical Assistance for Quality Managementwww.nationalqualitycenter.orgwww.hivqual.org
AETC National Resource Center (NRC), www.aidsetc.orgClinical Manual for Management of the HIV-Infected Adult
Health Resources and Services Administration HIV/AIDS Bureau, http://hab.hrsa.gov/
A Guide to the Clinical Care of Women with HIV/AIDS
Centers for Disease Control and Prevention, http://www.cdc.gov/std/hpv/default.htm
Human Papillomavirus: HPV Information for CliniciansSTD Treatment Guidelines 2006
AIDSMAP, http://www.aidsmap.com/cms1032598.asp
http://www.nationalqualitycenter.org/http://www.hivqual.org/http://www.aidsetc.org/http://www.cdc.gov/std/hpv/default.htmhttp://www.aidsmap.com/cms1032598.asp
National Quality Center (NQC)41
Helpful Resources contd.
American Society for Colposcopy and Cervical Pathology, http://www.asccp.org/hpv.shtml#provider
Association of Reproductive Health Professionals, http://www.arhp.org/healthcareproviders/cme/webcme/index.cfm
HIVInsite,http://hivinsite.ucsf.edu/InSite?page=kb-00&doc=kb-06-04-01
Planned Parenthood, http://www.plannedparenthood.org/sexual- health/std/hpv.htm
http://www.asccp.org/hpv.shtml#providerhttp://hivinsite.ucsf.edu/InSite?page=kb-00&doc=kb-06-04-01http://www.plannedparenthood.org/sexual-health/std/hpv.htmhttp://www.plannedparenthood.org/sexual-health/std/hpv.htm
National Quality Center (NQC)42
Contacts
Grantee Presenters:
Christiana Care, Wilmington, Delaware
Robin Bidwell, RNCPerformance Improvement Manager,[email protected] 302-255-1307
Arlene BincsickHIV Program [email protected]
National Quality Center (NQC)43
Contacts contd.
Grantee example:Scranton Temple Residency ProgramPalliative Medicine Consult Service, Scranton, PA
Mary Lawhon Triano, CRNP-C, [email protected]
Shubhra Shetty, MD, [email protected]
National Quality Center (NQC)44
Contacts contd
Presenters:Lori De Lorenzo, MSN, [email protected] 571-333-1841
Nanette Brey Magnani, EdD, NQC and HIVQUAL [email protected], 508-735-6990(C), 508-735-6990 (O)
Funded by HRSAHIV/AIDS Bureau
National Quality Center (NQC)
888888--NQCNQC--QIQI--TATANationalQualityCenter.orgNationalQualityCenter.org
[email protected]@health.state.ny.us
Application of Quality Improvement: Cervical Cancer Screening Aug 25, 2008Presenters:Lori De Lorenzo, MSN, RNNanette Brey Magnani, EdD, NQC Grantee: Christiana Care Health SystemRobin Bidwell, RNC, Arlene Bincsick, HIV Program DirectorAgenda1. Focus on QualityHAB QI Initiative:Cervical Cancer ScreeningWhat was the Initiative?What were the Goals?Why Was it Undertaken?What was Done?Data-Related ActivitiesSystem of Care ActivitiesWomens Health & Wellness Workgroup2. Lessons From the FieldWhat do you do?What do you do?QI Intervention: Does this reflect a systems problem or a problem with individual provider processes?What do you do?Baseline data: WHERE IS YOUR DOT? What Are the Underlying Causes of Low Rates?Initial InterventionsResults: Baseline and Today Follow Up of Abnormal ResultsResults- Christian Care Health ServicesQuantitative and Qualitative ResultsScranton Temple Residency ProgramResults of Intervention 2The Real StoryMost Frequent Interventions for Pap Improvement QI Projects HIVQUAL DatabaseLink Between Cervical Cancer Screening & Patient Show Rates3. AddendumSlide Number 29A. Raise awareness of NeedA. Raise Awareness contdB. Patient Education/Incentives contdC. System of Care ChangesC. System of Care Changes contdD. Scheduling and Keeping AppointmentsD. Scheduling and Keeping Appointments Tools: Flow Diagram and Fishbone AnalysisExample: Clarify Current ProblemFlowchart Initial Process Through Sample Collection (Univ of Pittsburgh Medical Center)Example: Select the Process to Change (Fishbone Diagram (Univ. of Pittsburgh MC)Helpful ResourcesHelpful Resources contd.ContactsContacts contd.Contacts contdNational Quality Center (NQC)