application of quality improvement: cervical cancer screening cervical cancer... · application of...

Funded by HRSAHIV/AIDS Bureau

Application of Quality Improvement: Cervical Cancer Screening

Aug 25, 2008

Presenters: Lori De Lorenzo, MSN, RN

Nanette Brey Magnani, EdD, NQC Grantee: Christiana Care Health System

Robin Bidwell, RNC, Arlene Bincsick, HIV Program Director

National Quality Center (NQC)2

Agenda

1. Background on HABs Focus and Initiative2. Lessons from the Field

QI ProjectsExamples from Grantees

3. AddendumSpecific QI interventions (Ideas for Improvement)Fishbone diagram exampleResourcesContacts


1. Focus on Quality

Ryan White Grantees have quality management legislative mandates

Focus on quality by HAB Internal External

Interest on quality initiatives in variety of areas

Cervical cancer screeningPatient show rates


HAB QI Initiative: Cervical Cancer Screening


What was the Initiative?

An opportunity for HAB to look at a specific issue and effect change through application of quality improvement

2007: Year of the PapBureau-wide quality improvement initiative that focused on improving cervical cancer screening rates


What were the Goals?

Improve cervical cancer screening completion rates across programs

Raise awareness of PHS guidelines

Increase awareness of low completion rates Improve data being submitted to HAB

Increase capacity of providers to provide & document screening

Train POs to facilitate & discuss improvement activities


Why Was it Undertaken?

PHS Guidelines related to cervical cancer are established & fairly straightforward

Change can make a differenceAbnormal Pap smears are more than 4 times higher in HIV-infected women HIV-infected women have a higher prevalence of HPV infection HIV-infected women are 5 times more likely to develop squamousintraepithelial lesions (SIL) Invasive cervical cancer is an AIDS defining illness

Data indicated this is an area where improvement is needed

CADR, GPRA, DCBP Client Level Data, HIVQUAL, NRC study


What was Done?

Activities focused on 2 parallel tracksDataSystem of care

All focused on strategies to improve completion rates


Data-Related Activities

All available data reviewedCADR, GPRA, DCBP Client Level Data, HIVQUAL, NRC study

Additional study conducted to further explore issues related to data collection

Hindering & facilitating factors


System of Care Activities

Released NRC report on common system, cultural and social barriers

NQC conducted 2 TA calls on cervical cancer screening initiatives

Culled best practices from HIVQUAL grantees

Implemented training plan for POs to prepare them for discussion with grantees

PO Talking Points

AETC Workgroup created series of training materials & resources


HIV Screening & Womens Health curriculumClinical Issues Training of Trainers Package

Slide sets with talking points on: Pap smears and pelvic exams HPV Common STDs

System Issues Technical Assistance Package

Slide set on using a fishbone diagramGuidebook on assessing and remedying barriers to cervical cancer screening

www.aidsetc.org

Womens Health & Wellness Workgroup


2. Lessons From the Field

Scenario: Presentation of Aggregate Pap Test Data to HIV Quality Committee and providers.

Example: Annual Pap Test results: 18%; 42%...

Reaction:The data isnt correct.That doesnt reflect my percentages.Patients refuse and are always menstruating.


What do you do?

Scenario 1. Team agrees data may not be accurate. Decides to do Data QI Project.

Scranton Temple Residency Program in Scranton, PA

Compared data between CAREWare, Charts, and new EMR to ensure data accuracy for reporting

Achieved >90% accuracy and maintained achievement


What do you do?

Scenario 2: Team discusses results and concludes there is variability among providers. Decides to report data by provider.


QI Intervention: Does this reflect a systems problem or a problem with individual provider processes?


What do you do?

Scenario 3: The team agrees with the data and moves to do a Pap QI Project.

Christiana Care Health Services


Baseline data: WHERE IS YOUR DOT?

Site TotalNumber of Patients

Numberof Women

% withDocumentedPAP results inMedicalRecords

Wilmington 800 320 42%

Smyrna 140 58 53%

Georgetown 260 67 57%


What Are the Underlying Causes of Low Rates?

Brainstorm a list.


Initial Interventions

Wilmington:Established a nested Womens Only Clinic at the Wilmington Hospital Annex to improve access to womens health services and overcome some of these barriers

Ryan White Part D staff were assigned to the project and included a nurse practitioner, a primary care nurse, a pharmacist, and a social worker

Smyrna and Georgetown:Coordinated TransportationProvided incentivesPart D staff attended appointments with patients to outside providers


Results: Baseline and Today

0%10%20%30%40%50%60%70%80%90%

100%

Wilm Smy Ggtwn


Follow Up of Abnormal Results

Nurse Practitioner certified to perform on site colposcopies has improved follow up of abnormal results at Wilmington site

0%

10%

20%

30%

40%

50%

60%

Wilm Smyrna Gtwn


Results- Christian Care Health Services

The ONLY intervention that demonstrated SIGNIFICANT and SUSTAINABLE improvement was to include pelvic exams as part of routine office visit


Quantitative and Qualitative Results Scranton Temple Residency Program

Baseline: 2005 13%Intervention 1: Proactive effort to schedule

women for annual Pap Tests 2006 56%2007 50%

Intervention2: Initiated a Womens Health Clinic on Wednesdays with Nurse Practitioner and a gift Spa bag with toiletries and other personal care items


Results of Intervention 2

June 30, 2008116 Active women

3 refuse GYN care5 need to see GYN for care due to abn. Pap Test6 high risk issues (hospice/cancer care, life/chaos, pregnancy3 have received Pap Tests elsewhere; need doc.

63 of 99 remaining women current 36 of them currently need Pap Tests (2/3 of

whom STRP provides primary care)


The Real Story

The real story for STRP is the return rate and how comfortable women are coming back for their annual visits. Sister Ruth says, Once they come in, they are sold! They receive a gift for doing the right thing which has been very well received. The women feel special for that one hour and cared for by the health center. One woman said, I dont think of this as a clinic; this is my family. The opportunity to reach women on issues of obesity, depression and anxiety has been tremendous. I could give you an example for everyone. We at STRP are providing care to those with HIV that treats the person as an individual with dignity and respect along with excellent medical care.

Mary Lawhon Triano, CRNP-C


Most Frequent Interventions for Pap Improvement QI Projects HIVQUAL Database

31 Different Interventions System of Care:

Perform pap if needed during any scheduled appointment - 19

Scheduling and Keeping Appointments: Reminder letters and calls 10

Patient Education and Incentives 5Raise Awareness of Need


Link Between Cervical Cancer Screening & Patient Show Rates

Cervical Cancer Screening Initiative is one example of HABs increasing involvement in QM/QI

Key issue in completing cervical cancer screens can be part of a larger issue related to retaining patients in care


3. Addendum

Specific QI interventions (ideas for improvement) Fishbone diagram example Resources Contacts


Specific QI Interventions from Grantees


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 needNotice in chartAdd to template (St. Marys Family Practice, GJ,CO)


A. Raise Awareness contd

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 (16th St.CHC, Milwaukee)Include annual Pap test as a 5th vital sign, signal for alert (Brockton Neigh. Health Center.)Pap bulletin boardCAREWare to track who needs annual GYN/Pap (Philadelphia Fight-Jonathan Lax Treatment Center)


B. Patient Education/Incentives contd

$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 patients birthday (Univ of Illinois/College of Medicine, Peoria)

Explain data for abnormal Pap smears (Lancaster Gen. Hosp/PA)


C. System of Care Changes

Perform Pap test if needed during any appt. (Unity Health Care, 16th 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, ob/gyn (St. Joseph Medical Center, Reading, PA; Concilio de Salud Integral de Loiza/PR)

Integrate into annual physical exam (Lynn CHC, MA)


C. System of Care Changes contd

Team approach to discussing a multi- pronged approach (Gurabo CHC/PR)

Offer gyn exams at clinic (new offering, Puerto Rico CoNCRA)

Improve documentation from external providers (Southside Health Association, Chicago; Jordan Hosp/Access Project/MA, Lancaster Gen. Hosp/PA)

Womens health initiative (St. Marys 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)


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)


D. Scheduling and Keeping Appointments

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


Tools: Flow Diagram and Fishbone Analysis

Purpose of Flow Diagram: To determine steps in the process and to identify problems associated with particular steps. The analysis guides selection of improvement strategies.

Purpose of Fishbone Analysis: To determine underlying causes related to a problem. Once identified, causes are then prioritized. The analysis guides selection of improvement strategies.


Example: Clarify Current Problem Flowchart Initial Process Through Sample Collection (Univ of Pittsburgh Medical Center)

yes

no

yes yes yes

no no no

Pt. needs GYN

exam/visit

PCP visit I. New Patient: 1st Visit

PCP documents need for GYN exam @ next

visit

Next appointment is scheduled

Possible chart review in the future & assessed again

Need for GYN determined via: chart review, excel

PCP Appointment

visit kept

GYN testing

completed

Possible chart review in the future & reassessed

a. If patient cancelled, reschedule appointmentb. If no show, check again at next PCP visit

Determine reason: new OB, GYN care elsewhere, PCP not comfortable doing GYN exam, or patient scheduled

for exam at a future appointment

GYN exam completed during PCP visit

II. Return Visit Test/s completed and sent to lab


Example: Select the Process to Change (Fishbone Diagram (Univ. of Pittsburgh MC)

Limited Comprehensiveness of Women's Health Care

Exam, with decreasing percentage of women

having an annual pelvic examination

Patients

Patients cancel appointments

If RN doesn't check, pt. May not know of apt.

Pt menstruating & unable to complete exam

Pt refuses or is reluctant to have gyn exam

Pap, etc. done elsewhere & no reports sent to PACT

Pt with lack of understandingof importance of periodic paps/gyn exams

Procedure

Lack of patient reminder/trigger system

Cumbersome procedure for identifying who needs a pap/gyn

Identification at 12th month apt. doesn't allow for delays

Lack of systematic tracking of anniversary dates

Multiple patient clinics with less time to review records

Documentation is not standardized

Staff

Rushed during routine HIV care appointment, no time

Some providers may not prefer to do a gyn

MD available to do pap, but staff unavailable to assist

Supplies

Supplies are not easily accessible in the exam room

Place

Seating is limited in the exam room

No flow in room set-up

Privacy issues during gyn exam

Room set up is unworkable for patients and staff


Helpful Resources

Technical Assistance for Quality Managementwww.nationalqualitycenter.orgwww.hivqual.org

AETC National Resource Center (NRC), www.aidsetc.orgClinical Manual for Management of the HIV-Infected Adult

Health Resources and Services Administration HIV/AIDS Bureau, http://hab.hrsa.gov/

A Guide to the Clinical Care of Women with HIV/AIDS

Centers for Disease Control and Prevention, http://www.cdc.gov/std/hpv/default.htm

Human Papillomavirus: HPV Information for CliniciansSTD Treatment Guidelines 2006

AIDSMAP, http://www.aidsmap.com/cms1032598.asp

http://www.nationalqualitycenter.org/http://www.hivqual.org/http://www.aidsetc.org/http://www.cdc.gov/std/hpv/default.htmhttp://www.aidsmap.com/cms1032598.asp


Helpful Resources contd.

American Society for Colposcopy and Cervical Pathology, http://www.asccp.org/hpv.shtml#provider

Association of Reproductive Health Professionals, http://www.arhp.org/healthcareproviders/cme/webcme/index.cfm

HIVInsite,http://hivinsite.ucsf.edu/InSite?page=kb-00&doc=kb-06-04-01

Planned Parenthood, http://www.plannedparenthood.org/sexual- health/std/hpv.htm

http://www.asccp.org/hpv.shtml#providerhttp://hivinsite.ucsf.edu/InSite?page=kb-00&doc=kb-06-04-01http://www.plannedparenthood.org/sexual-health/std/hpv.htmhttp://www.plannedparenthood.org/sexual-health/std/hpv.htm


Contacts

Grantee Presenters:

Christiana Care, Wilmington, Delaware

Robin Bidwell, RNCPerformance Improvement Manager,[email protected] 302-255-1307

Arlene BincsickHIV Program [email protected]

mailto:[email protected]:[email protected]


Contacts contd.

Grantee example:Scranton Temple Residency ProgramPalliative Medicine Consult Service, Scranton, PA

Mary Lawhon Triano, CRNP-C, [email protected]

Shubhra Shetty, MD, [email protected]



Contacts contd

Presenters:Lori De Lorenzo, MSN, [email protected] 571-333-1841

Nanette Brey Magnani, EdD, NQC and HIVQUAL [email protected], 508-735-6990(C), 508-735-6990 (O)



National Quality Center (NQC)

888888--NQCNQC--QIQI--TATANationalQualityCenter.orgNationalQualityCenter.org

[email protected]@health.state.ny.us

Application of Quality Improvement: Cervical Cancer Screening Aug 25, 2008Presenters:Lori De Lorenzo, MSN, RNNanette Brey Magnani, EdD, NQC Grantee: Christiana Care Health SystemRobin Bidwell, RNC, Arlene Bincsick, HIV Program DirectorAgenda1. Focus on QualityHAB QI Initiative:Cervical Cancer ScreeningWhat was the Initiative?What were the Goals?Why Was it Undertaken?What was Done?Data-Related ActivitiesSystem of Care ActivitiesWomens Health & Wellness Workgroup2. Lessons From the FieldWhat do you do?What do you do?QI Intervention: Does this reflect a systems problem or a problem with individual provider processes?What do you do?Baseline data: WHERE IS YOUR DOT? What Are the Underlying Causes of Low Rates?Initial InterventionsResults: Baseline and Today Follow Up of Abnormal ResultsResults- Christian Care Health ServicesQuantitative and Qualitative ResultsScranton Temple Residency ProgramResults of Intervention 2The Real StoryMost Frequent Interventions for Pap Improvement QI Projects HIVQUAL DatabaseLink Between Cervical Cancer Screening & Patient Show Rates3. AddendumSlide Number 29A. Raise awareness of NeedA. Raise Awareness contdB. Patient Education/Incentives contdC. System of Care ChangesC. System of Care Changes contdD. Scheduling and Keeping AppointmentsD. Scheduling and Keeping Appointments Tools: Flow Diagram and Fishbone AnalysisExample: Clarify Current ProblemFlowchart Initial Process Through Sample Collection (Univ of Pittsburgh Medical Center)Example: Select the Process to Change (Fishbone Diagram (Univ. of Pittsburgh MC)Helpful ResourcesHelpful Resources contd.ContactsContacts contd.Contacts contdNational Quality Center (NQC)

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