Improving Cervical Cancer Screening Rates Nanette Brey Magnani

Improving Cervical Cancer Screening Rates Nanette Brey Magnani, Ed. D Consultant, National Quality Center 888 -NQC-QI-TA, National. Quality. Center. org breymagnan@aol. com, 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 Improving Cervical Cancer Screening Rates National Quality Center (NQC)

Agenda cont’d I. III. IV. Examples of GYN QI Interventions Resources Grantee Presentation Contacts Improving Cervical Cancer Screening Rates National Quality Center (NQC)

Discussion Points with Your Project Officers on HAB QI Initiative • • • 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!!! Improving Cervical Cancer Screening Rates National Quality Center (NQC)

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 Improving Cervical Cancer Screening Rates National Quality Center (NQC)

B. Collect Data: Sources of Data § CADR § HIVQUAL reports § CAREWare § Practice Management Systems/EMR § Billing data Improving Cervical Cancer Screening Rates National Quality Center (NQC)

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. Improving Cervical Cancer Screening Rates National Quality Center (NQC)

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% 2 nd Pap test or GYN referral made 2= 100% Improving Cervical Cancer Screening Rates National Quality Center (NQC)

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 National Quality Center (NQC)

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 Improving Cervical Cancer Screening Rates National Quality Center (NQC)

Display and Distribute Data Simple Tables Bar Charts Run Charts Improving Cervical Cancer Screening Rates National Quality Center (NQC)

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% Improving Cervical Cancer Screening Rates 2004 goal 75% 2004 2005 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% Improving Cervical Cancer Screening Rates National Quality Center (NQC)

B. Improving Care: Basics of QI Projects – Causal Analysis Tools: • Flow diagram • Fishbone diagram • Brainstorm Improving Cervical Cancer Screening Rates National Quality Center (NQC)

Example: Clarify Current Problem Flowchart Initial Process Through Sample Collection (Univ of Pittsburgh Medical Center) Improving Cervical Cancer Screening Rates National Quality Center (NQC)

Example: Select the Process to Change (Fishbone Diagram (Un. of Pittsburgh MC) Improving Cervical Cancer Screening Rates National Quality Center (NQC)

Example: Histogram Improving Cervical Cancer Screening Rates National Quality Center (NQC)

From Data To Improvement: Linking performance data to QI activities Improving Cervical Cancer Screening Rates National Quality Center (NQC)

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 Improving Cervical Cancer Screening Rates National Quality Center (NQC)

PDSA Cycle Plan, Do, Study, Act Improving Cervical Cancer Screening Rates National Quality Center (NQC)

Repeated Use of Cycle PDSA Measures Le ing m o fr n r a A S ta a D D S P A P D A P S D Hunches Theories Ideas A P Changes That Result in Improvement S D Implementation of change Wide-scale tests of change Follow-up tests Very small scale test Improving Cervical Cancer Screening Rates National Quality Center (NQC)

Example for PDSA Cycle Female clients receiving a pap test during any appointment if they need it A P S D D A T A A P S D D S P A Cycle 1 E: Implement and monitor result quarterly D S Cycle 1 D: Incorporate suggestions, P A A expand to third physician. P S Cycle 1 C: Continue with Dr. Z’s patients and D expand to NP J’s patients for third week. Cycle 1 B: Try out the second week with Dr. Z’s patients incorporating suggestions from 1 st week Cycle 1 A: Try out with Dr. Z’s patients the first week Improving Cervical Cancer Screening Rates National Quality Center (NQC)

PDSA Cycle (cont. ) Improving Cervical Cancer Screening Rates National Quality Center (NQC)

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 National Quality Center (NQC)

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% 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 National Quality Center (NQC)

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 Improving Cervical Cancer Screening Rates National Quality Center (NQC)

Example: Continue Monitoring to Sustain the Gains Improving Cervical Cancer Screening Rates National Quality Center (NQC)

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 National Quality Center (NQC)

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) Improving Cervical Cancer Screening Rates National Quality Center (NQC)

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 (16 th St. CHC, Milwaukee) Include annual Pap test as a 5 th 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) Improving Cervical Cancer Screening Rates National Quality Center (NQC)

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) Improving Cervical Cancer Screening Rates National Quality Center (NQC)

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 National Quality Center (NQC)

C. System of Care Changes • Perform Pap test if needed during any appt. (Unity Health Care, 16 th 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) Improving Cervical Cancer Screening Rates National Quality Center (NQC)

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 Co. NCRA) • 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) Improving Cervical Cancer Screening Rates National Quality Center (NQC)

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) Improving Cervical Cancer Screening Rates National Quality Center (NQC)

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 Improving Cervical Cancer Screening Rates National Quality Center (NQC)

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 National Quality Center (NQC)

Resources cont’d Tools Handout HAB QI Initiative: Cervical Cancer Screening: Areas for Exploration with Grantees Improving Cervical Cancer Screening Rates National Quality Center (NQC)

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 National Quality Center (NQC)

IV. Grantee Presentation Christiana Care Wilmington, Delaware Presenters: Arlene Bincsik, RN, Director HIV Program Robin Bidwell, RNC, Performance Improvement Manager Mary Kay Steinhaus, NP Improving Cervical Cancer Screening Rates National Quality Center (NQC)

V. Contacts Christiana Care, Wilmington, Delaware Robin Bidwell, RNC, Performance Improvement Manager, RBidwell@Christianacare. org 302 -255 -1307 Arlene Bincsick, HIV Program Director ABincsik@Christianacare. org Mary Kay Steinhaus, NP msteinhaus@Christianacare. org Improving Cervical Cancer Screening Rates National Quality Center (NQC)

contacts cont’d. Web Ex Presentation Faculty University of Pittsburgh Medical Center Linda Despines, RN, QM Coordinator, despinesla@upmc. edu, 412 -647 -5475 St. Mary’s Family Practice, Grand Junction, CO Lucy Graham, Lucy. Graham@stmarygj. org AIDS Resource Center/Wisconsin, Milwaukee Sharon O’Dwyer, Sharon. O'Dwyer@arcw. org Improving Cervical Cancer Screening Rates National Quality Center (NQC)