Rapid Cycle Improvement Model Applied To Chlamydial Screening
- Slides: 29
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 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 • 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
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 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 • 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 • 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 • 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 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 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 • 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 Building Re-Design Clinical Practice Sustain the Gain
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 • Continuous improvement Re-Design Clinical Practice Sustain the Gain
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 with cue·C (Y 2 P!)
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 ·WWrites confidential phone number on chart
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 clinic for Rx RN enters Rx into STD log book
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 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 = #CT Tests/(#Well Care Visits *Sexual Activity Rate
% 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 & 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, 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
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