Linda Juszczak, Interim Executive Director – NASBHC Tiffany A. Clarke, Program Associate – NASBHC September 21, 2008 Quality Improvement in SBHCs.

Linda Juszczak, Interim Executive Director – Linda Juszczak, Interim Executive Director – NASBHCNASBHC

Tiffany A. Clarke, Program Associate – NASBHCTiffany A. Clarke, Program Associate – NASBHC

September 21, 2008September 21, 2008

Quality Improvement in SBHCs

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Objectives Define terms and processes related to quality Review standards of care for children and

adolescents Review national quality improvement

initiatives related to children and adolescents Review standards of care in school health Identify measures of quality in school health Develop a strong comfort level as a trainer with

this content

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The Components of Quality

How to measure?What to measure?Standards: What is the grade or level

of quality?

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Definitions Quality of care is the degree to which health

services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (Institute of Medicine, 1990).

Quality assessment is the act of measuring quality of care, of detecting problems of quality, or of finding examples of good performance.

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Definitions

Quality assurance applies to an entire cycle of assessment which extends beyond problem identification, to verification of the problem, identification of what is correctable, initiation of interventions, improvements, and continual review to assure that identified problems have been adequately corrected and that no further problems have been engendered in the process.

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Definitions

Quality Improvement seeks to improve performance not just areas of unacceptable care. Quality improvement focuses on the processes of health care delivery and use of statistical approaches designed to reduce variations in those processes. (CQI, TQI)

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Evidence Based Decision Evidence Based Decision MakingMaking

Care should be based on:– the best available scientific knowledge and– should not vary illogically from clinician to

clinician or from place to place. Institute of Medicine ( IOM, 2006)

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The Process of Quality Improvement

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Methods: Quality by Inspection Theory of bad apples Find the bad apples and remove them Implies or establishes a threshold for

acceptability People are the cause of troubles Mortality data are used

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Methods: Theory of Continuous Improvement Problem is rarely related to the people but to the

process or the job design, failure of leadership, or unclear purpose

Need to understand and revise the production process

Use a variety of measures

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Methods: PDSA Cycle and Fundamental Questions for Improvement What are you trying to accomplish?How do you know if change =

improvement?What changes will result in improvement?

Langley et al, The Improvement Guide, 1996

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State objective of the cycle

Make predictionsDevelop plan to carry out cycle (who, what, where, when.)

Carry out the test.Document the problems and unexpected observations.

Begin analysis of the data.

Complete the analysis of the data.

Compare data to predictions.

Summarize what was learned.

What changes are to be made?

What will be the next cycle?

PDSA Cycle

Act Plan

DoStudy

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Repeated Use of the Cycle

A PS D

A PS DA PS D

D SP A

HunchesTheories

Ideas

ChangesThat Result

in Improvement

DATA

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PDSA Cycle Group Activity

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What Do You Measure? Structural Measures - the physical, financial and

organizational properties in which care is provided

Process measures - what is actually done in giving and receiving care and whether what is now known as “good” medical care has been applied

Outcome Measures - the effects of care on health status, knowledge, behavior and patient satisfaction

(Donabedian, 1966,1988,1992)

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Examples of Measures : Structural Staff credentials and training Physical environment Policy and procedures Supervisory practices

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Examples of Measures

Tests, treatment and clinical strategies in use

Comparison to a standard

Protocols

Total quality management methodologies

Focus on process through use of tools such as: process flow diagrams, cause& effect diagrams

Process Measures

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Examples of Measures: Outcomes

MorbidityMortalityPatient KnowledgePatient Satisfaction

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Joint Commission How care is delivered not prescriptive on

content of care - encourage best practice and innovation

Addresses level of performance for activities that affect the quality of care

Evaluates based on a set of standards of care, have to be in compliance with applicable standards AND intent of the standards

Analyze and evaluate the systems that drive operations and procedures

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Joint Commission Focus on activities with high volume, a degree

of risk and that tend to produce problems for staff or patients, and/or are costly

Need to establish a threshold for evaluation Frequency of data collection and review is

based on the significance of the event and the extent to which data reflects improvement

Can compare to other organization to improve performance (Benchmarking)

http://www.jcaho.org/standards

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Joint Commission - Standards

Patient focused functions– Patient rights and organizational ethics– Assessment of patients– Education– Continuum of care– Linguistically and culturally appropriate care

Organizational focused functionsStructures with functions

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Some “Hot” Areas –Joint Commission

Environment of care - is space equipped to provide care

Patient education activities (food-drug-drug/drug interactions, anticipatory guidance)

Medication management to reduce error Patient outcomes- vigorous analysis of practice Documentation in medical record Patient safety (new 7/01 now majority of

standards)

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Joint Commission - Improving Organizational Performance

Data are systematically aggregated and analyzed on an ongoing basis

Improved performance is achieved and sustained.

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Joint Commission

Beginning January 1, 2006, on-site surveys for accredited ambulatory care organizations and office-based surgery practices will be unannounced.

NP and PA credentialing process is becoming increasingly important

HEDIS 2009HEDIS 2009Weight assessment and counseling for

nutrition and physical activity for childrenChildhood immunizationChlamydia screening Appropriate testing for children with

pharyngitisAppropriate treatment for children with upper

respiratory infectionFollow up care for children prescribed with

ADHD medication

HEDIS 2009HEDIS 2009Children with chronic conditionsChildren and adolescent access to primary

care practitionersUse of appropriate medications for people

with asthmaFollow up after hospitalization for mental

illnessMedical assistance with smoking cessationAnnual dental visit

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Chart Reviews

How many?- < 30 visits do 100%, 30- <600 do 10%, > 600 do 5%

Need to be done to monitor medical and behavioral health record compliance- NCQA, Joint Commission, Insurance companies

Do focused reviews at the same time- CQI Tool or others

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What else do you need to do?

A person on staff is responsible for CQI Monitor the environment of care Written policies and procedures in place Written scope of care Patient satisfaction measured periodically Regular tracking of key variables to monitor

operations: no shows, cancellations, new to revisit ratio, apt to walk in ratio.

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Discussion

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Selecting a Standard of Care

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Guidelines for Review

US Preventive Services Task Force

Bright Futures GAPS

American Academy of Family Physicians

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Standards of Care : Themes

ComprehensivePeriodicEmphasis on prevention and educationCertain conditions/issues appear over

and over

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Considerations In Guideline Selection

Age of your patient populationCharacteristics of your clinical practicePracticality of implementing in your

practiceAre there tools that can be used

effectively?Are there systems in place to document

and measure quality?

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Quality Improvement Initiatives Related To Children And Adolescents

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An Emerging National Agenda

Crossing the Quality Chasm (IOM, 2001)National Health Care Quality Report

(IOM, 2001)National Academy of Science call for

system of rewards based on performance ( NY Times, October 31st, 2002)

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FACCT

(The Foundation for Accountability- Closed)

Dedicated to helping consumers have information they need to make better decisions about their health care. Formulates measures that consumers find relevant and easy to understand.

Child and Adolescent Health Measurement Initiative (CAHMI) - measure development– Young Adult Health Care Survey– Living with Illness– Promoting Healthy Development

Measures tested, submitted to HEDIS, used for plan QI, consumer information development, and research studies

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Child and Adolescent Health Measurement Initiative (CAHMI) - Young Adult Health Care Survey (YAHCS)

Measures not just receiving care but the quality of care that adolescents receive for accountability purposes

Collaboration between NCQA, AAP, Children Now!,CDC, AHRQ, etc

Focus is on preventive care and align with national recommendations

Adolescents’ asked directly about the care they received

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CAHMI - YAHCS

Adolescent Preventive Care (14-18 year olds) 56 questions

– Health care use– Privacy– Health and safety– Health information– Health care in the last 12 months– Your health – Demographics

Reliable and valid

http://dch.ohsuhealth.com/index.cfm?pageid=451&sectionID=133&open=148

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Consumer Assessment of Health Plan Survey (CAHPS)

Instrument in development that is intended to capture information about the experience and satisfaction adolescents’ report about basic aspects of care such as access and communication with providers.

Shares 20 items with YAHC Parents complete survey first then have

adolescents complete

https://www.cahps.ahrq.gov/default.asp

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NICHQ: National Initiative for Child Health Quality

An action-oriented organization dedicated solely to improving the quality of health care provided to children.

Mission is to eliminate the gap between what is and what can be in health care for all children.

http://www.nichq.org

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NICHQ: National Initiative for Child Health Quality

AsthmaADHDChildren with special healthcare needsChildren in foster carePreventive careCultural competencyObesity

http://www.nichq.org

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2005 National Health Care Disparities 2005 National Health Care Disparities ReportsReports

Proportion of children whose parents report getting advice on physical activity is lower among poor and near poor children.

Childhood asthma admission rates are highest among black children

Many racial and ethnic minorities and persons of lower socioeconomic position are less likely to receive childhood immunizations

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Issues Influencing Mental Issues Influencing Mental Health and CQIHealth and CQI

Limited evidence base and variations in care especially for children

Diversity of providersCharacteristics that distinguish mental

health from general health careCharacteristics of SBHC practiceChartingLess well developed infrastructure for

quality measurement

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Organizations And Initiatives Organizations And Initiatives Conducting Systematic Evidence Conducting Systematic Evidence Reviews Related To Mental HealthReviews Related To Mental Health

Cochrane Group (developmental, psychosocial and learning problems)

USPSTF (suicide risk)National Registry of Evidence Based

Programs and Practice (brand name programs for prevention, CBT, multisystemic therapy)

Agency for Healthcare Research and Quality (AHRQ) - ADHD

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Organizations and Initiatives Organizations and Initiatives Conducting Systematic Evidence Conducting Systematic Evidence ReviewsReviews

DOJ Federal Collaboration on What Works (prevention, intervention, treatment for juvenile justice, drug and ETOH)

Professional Associations

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How Organizations Respond To Problems And Opportunities To Improve

Pathological: hide information, shoot the messenger, cover failures, crush new ideas

Bureaucratic: ignore information, tolerates messengers, promotes self as just and merciful, new ideas= problems

Generative: information is sought, messengers are trained, failures lead to inquiry , new ideas are welcomed

(Westrum,2004)

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The Learning Organization“…organizations where people continually

expand their capacity to create the results they desire, where new and expansive patterns of thinking are nurtured, where collective aspiration is set free, and where people are continually learning to see the whole together.”(Senge,1990)

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The Learning OrganizationThere is a process of self examination and

continuous improvementOpenness and collaboration (patient

centered care)The best have the capacity to learn, adapt

and improve the fastest

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Patient centered careOpenness drives improvementWell being of patients is paramountPeople should be able to learn anything

that affects their lives

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Why be transparent?Leads to greater improvementInvolves parents and usersIncludes a view of why problems exist that

you would not have considered beforeThere is by in from all involved to

improve

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What needs to happen in order to be transparent

Commitment to changeCreation of a culture of transparency

– Leadership– Re train staff– Regular reporting mechanism– Project level data – it is not about the

individual– Opportunities to practice being transparent

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RisksThe blame gameFear users will stop using the serviceFears regarding loss of position -status,

jobs etc

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Recommendations from NASBHC: Share your improvement data

Academic Success: with the schoolProductivity: with stakeholdersCQI Tool: with insurers and employers…now with users and families.

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Learning more about a culture of transparency

The Bell Curve, Atul Gawande (2004) http://www.newyorker.com/fact/content/?041206fa_fact

When Things Go Wrong (Harvard teaching institutions) http://www.ihi.org/NR/rdonlyres/A4CE6C77-F65C-4F34-B323-20AA4E41DC79/0/RespondingAdverseEvents.pdf

Pursuing Perfection- Cincinnati Children's

http://www.cincinnatichildrens.org/about/perfect/

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The patient has a right to transparency

“Nothing about me without me”Caregivers have no moral or legal

authority to withhold informationWithholding information is arrogant and

disrespectfulNot knowing causes anger, resentment and

loss of trust

(Leape, Atlanta, IHI IMPACT Mtg May 2006)

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Pay for Performance The goal of pay-for-performance programs

should be to align reimbursement with the practice of high quality, safe health care for all consumers.

Controversial Complicated Cost reduction vs incentives Becoming more widely implemented. Providers

in HMOs being paid based on their performance.

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Standards of Care for SBHCs

Historical

– Funders

– StatesNASBHC (Principles, CQI Tool, MHPET,

Collaboratives, Productivity)

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BREAK

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Best practice in SBHCs:

Standards, Principles, Program Evaluation, and

Evaluation of Clinical Care

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Principles for SBHCs

Supports the school Responds to the community Focuses on the student Delivers comprehensive care Advances health promotion activities Implements effective systems Provides leadership in adolescent and child

health

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A Program Evaluation Tool for SBHCs The 7 principles and their goals Structures needed to implement the goals - the

physical and organizational properties of the environment

Processes to support the goals - what is done to achieve the desired outcome

Outcomes that can be attributed to a desirable performance - satisfaction, behavior,morbidity

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Examples of Outcomes Reduced number of

students who leave school during the day due to illness

High parent satisfaction

Increased enrollment for and utilization of SBHC services

Patient perception that well-being has improved

Increased compliance rates as measured by follow-up visits completed, prescriptions filled, therapy attended, referrals completed etc.

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Questions Regarding Measurement of Quality in SBHCs

Are the things we want to measure truly important to the health of students?

Do the measures identify good health and care?

Can clinical practice make an impact on these conditions?

Are the measures practical?Do they work in the field?

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Mental Health Planning and Evaluation Template (MHPET)

34 indicator measure which evaluates eight dimensions related to providing mental health services in schools– Operations– Stakeholder involvement– Staff and training– Identification, referral and assessment– Service delivery– School coordination and collaboration– Community coordination and collaboration– Quality assessment and improvement

www.nasbhc.org

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Evaluation of Clinical Services in SBHCs (CQI Tool)

Sentinel conditions as a marker of the quality of clinical care

The foundation is an annual risk assessment and biennial physical exam

Limited number of conditions allows for meaningful evaluation

Intent is for the tool to be flexible

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The SBHC CQI Tool Six conditions per age group (choose one of two

mental health conditions) References to support the inclusion of the

condition and to use to improve performance Resources necessary to provide quality care

relative to that sentinel condition Markers of care for that condition Measurement of the markers on a scale of 1 to 5

with threshold at 3

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Sentinel Conditions for Elementary School (CQI Tool)

Annual risk assessment and physical exam Asthma Risk for Type 2 diabetes Poor School Performance Oral Health Mental health

– Depression

– Psychological trauma

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Sentinel Conditions for Middle School and High School (CQI Tool)

Annual risk assessment and physical exam Asthma Risk for Type 2 diabetes Tobacco use Substance use Chlamydia screening Immunizations Poor School Performance Oral Health Mental health

– Depression

– Psychological trauma

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SBHC CQI Tool

The toolData collection formsInstructionsResources/glossary/directoryGuide to sampling populations

http://www.nasbhc.org

CQI GlossaryCQI Glossary

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Why Is Improving Practice a Problem?

The demand for services keeps you reacting to crises and acute care requests

Lack of administrative support (school and SBHC operations/budget)

Effect on productivity

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Why Is Improving Practice a Problem?

ReimbursementLack of parental involvementForces the providers to address the “hard”

issuesSBHC needs the partnerships/referral

relationships to support providing preventative services

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Why Does It Matter?

Consistent with a standard of care Realizes the potential of the SBHC model Valued by insurers, government, parents, the

community and students themselves (?) Focused on finding adolescents at risk or already

in trouble Staff satisfaction

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Essential Elements for Successful Prevention in SBHCs (NASBHC)

A prevention mission A supportive environment for students A competent staff Collaborative partnerships for prevention Effective strategies Accountability

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Factors Associated with Successful Adoption of Innovations: Organizational Adopters

Decentralized decision making Can identify, capture, share and integrate new

knowledge Receptive to change through strong leadership,

clear vision, good management and climate conducive to experimentation and risk taking

Effective data systems Ready for change

Greenhalgh et al 2004

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NASBHCs Benchmarking Efforts

Compare yourself to other apples not oranges Document the SBHC experience for

improvement and advocacy Tools

– CQI ( revision in 2008)

– Productivity ( on web www.nasbhc.org)

– Cost ( in development, contact [email protected] if interested in participating in beta test)

– MH PET ( on web www.nasbhc.org)