Rapid Cycle Improvement Model Applied To Chlamydial Screening

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Rapid Cycle Improvement Model Applied To Chlamydial Screening in Teens A Partnership Between: Kaiser

Rapid Cycle Improvement Model Applied To Chlamydial Screening in Teens A Partnership Between: Kaiser Permanente Northern California & University of California, San Francisco Mary-Ann Shafer, MD Division of Adolescent Medicine UCSF Supported by the Agency for Health Care Research and Quality & the Centers for Disease Control and Prevention 1

Objectives • Increase chlamydial (CT) screening of sexually active teen girls to meet HEDIS

Objectives • Increase chlamydial (CT) screening of sexually active teen girls to meet HEDIS guidelines • Develop, implement and evaluate a systemsbased intervention that capitalizes on existing clinic resources while addressing barriers to CT screening using a rapid cycle approach

Background Facts About Chlamydia trachomatis (CT) • CT-most common reportable STI in teens •

Background Facts About Chlamydia trachomatis (CT) • CT-most common reportable STI in teens • Most asymptomatic-in males and females • NAATs- 90 -95% sens & spec feasible • National Guidelines annual CT screen (e. g. CDC, USPSTF, AAP, ACOG, AMA) • Only 25% of eligible population being screened

JAMA December 11, 2002

JAMA December 11, 2002

Learning Objectives • Review the development, implementation and evaluation of a systems-based rapid cycle

Learning Objectives • Review the development, implementation and evaluation of a systems-based rapid cycle clinical improvement intervention (CPI) to increase CT screening • Discuss the application of the CPI model to different clinical settings including identifying and overcoming barriers to success

% Change in STD Screening Rate Rapid Cycle Changes Rapid Cycle Applied To CT

% Change in STD Screening Rate Rapid Cycle Changes Rapid Cycle Applied To CT Screen • Recruit team • Problem solve at monthly meetings • Apply solutions & assess each month • Repeat, sustain Status Quo Time in months

% Change in STD Screening Rate Rapid Cycle Changes Step 1: • Set Goal

% Change in STD Screening Rate Rapid Cycle Changes Step 1: • Set Goal • Define measure • Identify barrier(s) • Decide solution • Try it out Status Quo Time in months

% Change in STD Screening Rate Rapid Cycle Changes Step 2 • Assess trial

% Change in STD Screening Rate Rapid Cycle Changes Step 2 • Assess trial • Identify next barriers • Decide solution • Try it out Status Quo Time in months

% Change in STD Screening Rate Rapid Cycle Changes Step 3 • Assess trial

% Change in STD Screening Rate Rapid Cycle Changes Step 3 • Assess trial • Identify barriers • Decide solution • Try it out • Repeat “cycles” • Sustain gains Status Quo Time in months

Setting for Rapid Cycle Application Setting Large HMO in Northern California: KP • 10

Setting for Rapid Cycle Application Setting Large HMO in Northern California: KP • 10 pediatric clinics randomly assigned: 5 -well care intervention and 5 control groups • 2 of 5 intervention clinics target both well and urgent care visits

Methods KP Pediatric Setting cont. Well-Care Visit Urgent-Care Visit • Appointment required • Physical

Methods KP Pediatric Setting cont. Well-Care Visit Urgent-Care Visit • Appointment required • Physical exam (every 2 -3 yrs) • 20 minute visit • • Same/next day visit Sick/non-ER visit 10 minute visit Same physical setting as WCV • Same providers & staff as WCV

Clinical Practice Improvement Model Engage Team Building Re-Design Clinical Practice Sustain the Gain

Clinical Practice Improvement Model Engage Team Building Re-Design Clinical Practice Sustain the Gain

Clinical Practice Improvement Model • Leadership Engage • Best practices Team Building • Define

Clinical Practice Improvement Model • Leadership Engage • Best practices Team Building • Define gap Re-Design Clinical Practice • Raise Awareness Sustain the Gain

Clinical Practice Improvement Model • ACTeam • Skill building • Tool Kit Engage Team

Clinical Practice Improvement Model • ACTeam • Skill building • Tool Kit Engage Team Building Re-Design Clinical Practice Sustain the Gain

Clinical Practice Improvement Model Engage • Customize • Measure success Team Building Re-Design Clinical

Clinical Practice Improvement Model Engage • Customize • Measure success Team Building Re-Design Clinical Practice Sustain the Gain

Clinical Practice Improvement Model Engage Team Building • Monitor performance • Time series analysis

Clinical Practice Improvement Model Engage Team Building • Monitor performance • Time series analysis • Continuous improvement Re-Design Clinical Practice Sustain the Gain

Site Specific Flow Chart Cue Charts ID eligible teens ·C Charts are stamped with

Site Specific Flow Chart Cue Charts ID eligible teens ·C Charts are stamped with cue Room Patient MA collects FVU on all 14 -18 yo F ·TTeen takes FVU sample to exam room MD/NP VISIT MD/NP obtains sex hx If sexually active, MD completes CT lab slip ·W ·WWrites confid. # on chart Urines To Lab Follow. Up MA refrigerates FVUs · A enters teen name, confidential # in clinic log book ·LRunner takes FVU to lab RN contacts CT + teen: confid. # Teen comes to clinic for Rx RN enters Rx in STD log book

1. Cue Charts ·IIdentify eligible (target) population (14 -18 y teens) · Charts stamped

1. Cue Charts ·IIdentify eligible (target) population (14 -18 y teens) · Charts stamped with cue·C (Y 2 P!)

2. Room Patient ·MMA collects FVU on all 14 -18 yo ·TTeen takes FVU

2. Room Patient ·MMA collects FVU on all 14 -18 yo ·TTeen takes FVU sample to ·C exam room ·a

3. VISIT ·CMD/ NP obtains sexual hx ·IIf sexually active, MD completes·CCT lab slip

3. VISIT ·CMD/ NP obtains sexual hx ·IIf sexually active, MD completes·CCT lab slip ·WWrites confidential phone number on chart

4. Urines to Lab ·CMA refrigerates FVUs · MA enters teen name, confidential phone

4. Urines to Lab ·CMA refrigerates FVUs · MA enters teen name, confidential phone number in ·C log book ·LRunner takes FVU to lab

5. Follow-up RN contacts CT + teen: confidential phone number ·C Teen comes to

5. Follow-up RN contacts CT + teen: confidential phone number ·C Teen comes to clinic for Rx RN enters Rx into STD log book

Clinician’s Top Barriers to CT Screening in Primary & Urgent Care Settings 1. CONFIDENTIALITY:

Clinician’s Top Barriers to CT Screening in Primary & Urgent Care Settings 1. CONFIDENTIALITY: How separate parent? 2. TEEN SEX HX: How do I ask these things? 3. PRIORITIES: How competes in urgent care? 4. JOB DESCRIPTION: Is this part of my job? 5. PAYMENT: Who’s responsible? 6. POSITIVE CT RESULT: What do I do now?

Key Barriers Sample Solutions Confidentiality Universal urine collection Teen’s sexual history Teen-friendly rooming policy

Key Barriers Sample Solutions Confidentiality Universal urine collection Teen’s sexual history Teen-friendly rooming policy Site Teen Health Champion Anonymous chart reviews Priorities for limited time Re-think visit priorities Payment – copays Waived to protect teens small price to pay! Positives tests FU protocol in place

RESULTS Female CT Screening Rates* Pediatric Well-Care Visits (14 -18 yo) *Chlamydia Screening Rate

RESULTS Female CT Screening Rates* Pediatric Well-Care Visits (14 -18 yo) *Chlamydia Screening Rate = #CT Tests/(#Well Care Visits *Sexual Activity Rate

% SA Females Screened for CT RESULTS: Female CT Screening Rate in Urgent Care

% SA Females Screened for CT RESULTS: Female CT Screening Rate in Urgent Care Pilot Sites A A B B

Results of Intervention Evaluation • Dramatic improvement in well & urgent clinics • Sustainable

Results of Intervention Evaluation • Dramatic improvement in well & urgent clinics • Sustainable & cost-effective • Clinic differences in approach rate of improvement varies • One solution does not fit all even within HMO

Implications • Rapid cycle quick, customized & sustained • Effective in different settings- well,

Implications • Rapid cycle quick, customized & sustained • Effective in different settings- well, urgent care & may be applied as a quality assurance tool • Capitalizes upon existing resources & staff • Small changes LARGE effects • Gives chronically over-worked staff sense of importance, success & control over workplace