maricopa integrated health system

Funded by HRSAHIV/AIDS Bureau

Using the PDSA Cycle Using the PDSA Cycle to Successfully to Successfully Implement an HIV Implement an HIV Rapid Testing Rapid Testing Program in Hospital Program in Hospital Labor & DeliveryLabor & Delivery by Debra Welbornby Debra WelbornMaricopa Integrated Health SystemMaricopa Integrated Health System

Funding by the Department of Health and Human Services, Health Resources and Service Administration, the Ryan White CARE Act Amendments of 2000 and the Maricopa Integrated Health System

National Quality Center (NQC)2

Maricopa Integrated Health System

• Maricopa Integrated Health System (MIHS) is is a special health care district in Phoenix, AZ

• MIHS includes: Acute care hospital, Maricopa Medical

Center, with 449 beds 12 ambulatory health centers including an

HIV (Ryan White) health center, Psychiatric services, Arizona burn center,

Level 1 trauma center.• MIHS is the grantee in Maricopa County,

Arizona for: Title III since 1991- 1563 clients, Title IV since 1998- 988 clients Title I since 1994 and Title II since 2005


Maricopa Integrated Health System

• Maricopa Medical Center (MMC) is #3 in Maricopa County for the largest number of deliveries for uninsured, indigent and refugee women.

• As a Title IV initiative, MMC went “live” on July 1, 2005 with its program: ‘HIV Rapid Testing in Labor & Delivery’. Criteria:

Ensure that Rapid HIV test is offered to 100% of moms (in

imminent labor) who do not already have a documented HIV

test or who are at high-risk of contracting HIV during the

pregnancy

Ensure effective pre-test & post-test counseling with

appropriate referrals


Challenges in Using Data

• Trouble collecting data: The only way to identify women with no prenatal care is with

the manual labor log. Electronic reports are unavailable. The only way to identify women with high risk factors is through

a chart review of 100% of deliveries. The only way to compute compliance rates is not with a lab

monitoring log, but through chart reviews of electronic medical records.

• Problems sharing data: Data is shared through the Perinatal PI Committee with the

department heads. The information, however, is not always communicated to other practitioners.


Challenges in Using Data

• Difficulties with analyzing data: Chart Reviews are time consuming: Except for lab results,

information is ‘hidden’ in the margins of progress notes, nurses notes or labor & delivery notes.

• Follow-up problems: Minimal, but includes staffing changes, priorities and

limited resources remain.

• Sustainability issues: Human resources for data collection and analysis are

limited.


Solutions

• MIHS Implemented a CQI Study methodology as illustrated in the Venn Diagram:

Process

changes

Chart Review-

PhysicianSatisfaction Survey

Adoption and

continuous review of national

standards

Lab Monitoring


Improvement Projects

PLAN: Review national data and guidelines;Attend CDC conference;Meet with hospital who had implemented a program 9

months prior to MIHS; Create project team to implement program;Train nurses, social workers, physicians, residents, lab

personnel and others on new program;Obtain approval from hospital compliance officer &

verify HIPAA compliance.

DO:Adopt local protocols, guidelines and procedures“GO LIVE” on July 1, 2005;Implement QI Plan and study methodologies;Create brochures & give presentations to local staff as

well as to other hospitals.

PDSA cycles were crucial to the success of the program:



Study: Monthly lab monitoring: actual # of tests.Quarterly medical record reviews:compliance rates.Annual physician satisfaction survey.

ACT:Co-sponsor OB High-risk Conference with CDC

speaker- Dr. Branson.Continue training staff, physicians and residents.Present data at quarterly Perinatal PI meetingsSend individual cases to Peer ReviewChange processes as appropriate- e.g. change

lab procedures, eliminate ELISA testsImplement Phase II at hospital: Re-testing moms

who have new risk factors.

PDSA cycles were crucial to the success of the program:


Lessons Learned

• You can start a new program and implement a PDSA cycle without total physician buy-in, but it’s problematic. Adjustments are required and improvements are gradual.

• Consultation/training from known “experts” are essential to the CQI process- they provide credibility as well as motivation for local practitioners.



HIV Rapid Tests in L & D at MMC

7

13

32

910

16

13

16

14

17

0

2

4

6

8

10

12

14

16

18

HIV Test Results: One (1) False Positive Test -July 2005. (Western Blot was negative)

No (0) True HIV Positive Tests

225

250

275

300

325

350

375

400

425

450

475

500

525

550

575

2001 2002 2003 2004 2005 2006

2001 484 377 430 409 392 446 503 522 485 506 503 498

2002 464 434 405 433 416 402 454 561 495 473 411 397

2003 373 324 322 306 338 334 373 404 389 409 396 378

2004 390 346 320 296 319 318 418 363 347 375 340 354

2005 314 287 312 271 278 278 342 325 307 303 305 316

2006 256 321 289 256 263

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total

5555

5345

4346

4186

3638

1385

MMC Births: Approximately 300+/month



HIV Rapid Testing in L & D-Process and Outcome Measurements

for FY05-06

Goal Results- August 05 n=317

Results-4th Quarter 05n=99

Results-1st Quarter 06n=130

Results2nd Quarter06 n=120+

Number of Rapid tests performed/total number of women in imminent labor who have had no prenatal care (‘defined as 0-1 prenatal care visits’) (% Compliance Rate)- L & D Only

>50%

45%

25%

56%

>70%

Number of women who have had at least 1 HIV test during current prenatal care/total number of women who delivered at MMC & excludes those that declined (% Compliance Rate) (FHCs & physician offices)

>90%

93%

90%

98%

>95%


Stay Tuned for Part II

• MIHS’ initiative includes providing technical assistance to all other hospitals with L & D departments in Maricopa County who have not yet implemented an HIV Rapid Testing Program.

• MIHS & AETCs are looking at ways to partner on HIV Rapid Testing programs.

• For further information contact: Debra Welborn, Title IV Program Coordinator at 602-344-2628. See also www.mihs/org/ryanwhite

maricopa integrated health system

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