Missed Opportunity vs UpToDate Status AFIX Plus John

Missed Opportunity vs Up-To-Date Status: AFIX Plus John Fontanesi, Ph. D Howard Backer, MD 1

AFIX: What We Know p One of the more powerful mechanisms for improving community converge rates p “Fits” into a quality improvement framework Collect data about a process n Analyze “inputs” and “outputs” n Develop an action plan from data n Re-measure n Evolve n 2

Expanding the Model: Using Guiding Measurements p Measurements should inform and not “grade” p Measurements should be SMART S imple n M easurable n A ccessible n R elevant n T imely n 3

Expanding the Model: Using Guiding Measurements p As improvement occurs, assessment and feedback goals change Decrease the burden of measurement n Look for antecedent and proxies n Move measurements closer to point of service n Move from external audit to internal review n 4

The Challenge Need a measurements and feedback system that: p Acknowledges Clinic Staff p n n Are overwhelmed Have external accountabilities Are evaluated based upon what is achieved Often feel undervalued Can provide large scale implementation at multiple sites p Maintain methodological rigor p Are cost-effective p Everyone wants immediate results p 5

Moving from UTD Status to Missed Opportunities: AFIX PLUS q Providers want more immediate feedback n n q UTD happens once a year MO happens at least quarterly Change takes 2 years to be fully represented in UTD Change takes 3 months to be fully represented in MO Administration wants to distinguish between individual provider practices vs. “system issues” (e. g. , no vaccine available) n n UTD is an ”output” at the clinic level – it can not be associated with “cause” MO can identify causes 6

Moving from UTD Status to Missed Opportunities: AFIX PLUS “Pay for Performance” requires peer-review p Need mechanisms for doing several quality measures at once p n n Over 500 Published Preventative Care Guidelines Average Facility undergoes 36 external audits UTD is a “protocol” that must compete with other auditing goals Missed Opportunity is a “Process” that can (and should) accommodate multiple preventive activities (e. g. , BMI, Ha 1 c, lipid screening, asthma management) 7

AFIX Plus Process Done by the providers’ staff p Measures missed opportunities p Occurs at least quarterly p n n Five charts for each provider Reviewed by Medical Director or designee Feedback given immediately p Can include other preventive measures p Public health personnel act as resident experts p n Provide tools, training and protocols 8

Convert to Categories of Errors Problem Area Occurrences Fail to Document 35 No Time 25 Didn't know 21 Vacine shortage 18 missing IZ record 13 IZ record wrong 12 Parent didn't want all 10 PR didn't want all 7 other 5

Added Benefits p Immunization “Consultant”: Facilitates instead of audits n Monitors process instead of outcome n Perceived as an expert in QI n Captures best practices and disseminates solutions to common problems n Leverages FTE over greater number of practices n Provides large epidemiological dataset n

What Can Go Wrong ? p Practice can self delude or “game” the process p Vaccination” Consultants” may be asked to contribute to non-vaccination QI activities p Reluctance to let go of “Gold Standard” Up -To-Date status n May be better done as national survey? 17

QUESTIONS? 18