1. Linda Juszczak, Interim Executive Director – NASBHC Tiffany A. Clarke, Program Associate – NASBHC September 21, 2008 Quality Improvement in SBHCs

2. 2 Objectives Define terms and processes related to quality Review standards of care for children and adolescents Review national quality improvement initiatives related to children and adolescents Review standards of care in school health Identify measures of quality in school health Develop a strong comfort level as a trainer with this content

3. 3 The Components of Quality How to measure? What to measure? Standards: What is the grade or level of quality?

4. 4 Definitions Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (Institute of Medicine, 1990). Quality assessment is the act of measuring quality of care, of detecting problems of quality, or of finding examples of good performance.

5. 5 Definitions Quality assurance applies to an entire cycle of assessment which extends beyond problem identification, to verification of the problem, identification of what is correctable, initiation of interventions, improvements, and continual review to assure that identified problems have been adequately corrected and that no further problems have been engendered in the process.

6. 6 Definitions Quality Improvement seeks to improve performance not just areas of unacceptable care. Quality improvement focuses on the processes of health care delivery and use of statistical approaches designed to reduce variations in those processes. (CQI, TQI)

7. 7 Evidence Based Decision Making Care should be based on: – the best available scientific knowledge and – should not vary illogically from clinician to clinician or from place to place. Institute of Medicine ( IOM, 2006)

8. 8 The Process of Quality Improvement

9. 9 Methods: Quality by Inspection Theory of bad apples Find the bad apples and remove them Implies or establishes a threshold for acceptability People are the cause of troubles Mortality data are used

10. 10 Methods: Theory of Continuous Improvement Problem is rarely related to the people but to the process or the job design, failure of leadership, or unclear purpose Need to understand and revise the production process Use a variety of measures

11. 11 Methods: PDSA Cycle and Fundamental Questions for Improvement What are you trying to accomplish? How do you know if change = improvement? What changes will result in improvement? Langley et al, The Improvement Guide, 1996

12. 12  State objective of the cycle  Make predictions  Develop plan to carry out cycle (who, what, where, when.)  Carry out the test.  Document the problems and unexpected observations.  Begin analysis of the data.  Complete the analysis of the data.  Compare data to predictions.  Summarize what was learned.  What changes are to be made?  What will be the next cycle? PDSA Cycle Act Plan DoStudy

13. 13 Repeated Use of the Cycle A P S D A P S D A P S D D S P A Hunches Theories Ideas Changes That Result in Improvement DATA

14. 14 PDSA Cycle Group Activity

15. 15 What Do You Measure? Structural Measures - the physical, financial and organizational properties in which care is provided Process measures - what is actually done in giving and receiving care and whether what is now known as “good” medical care has been applied Outcome Measures - the effects of care on health status, knowledge, behavior and patient satisfaction (Donabedian, 1966,1988,1992)

16. 16 Examples of Measures : Structural  Staff credentials and training  Physical environment  Policy and procedures  Supervisory practices

17. 17 Examples of Measures Tests, treatment and clinical strategies in use Comparison to a standard Protocols Total quality management methodologies Focus on process through use of tools such as: process flow diagrams, cause& effect diagrams Process Measures

18. 18 Examples of Measures: Outcomes Morbidity Mortality Patient Knowledge Patient Satisfaction

19. 19 Joint Commission How care is delivered not prescriptive on content of care - encourage best practice and innovation Addresses level of performance for activities that affect the quality of care Evaluates based on a set of standards of care, have to be in compliance with applicable standards AND intent of the standards Analyze and evaluate the systems that drive operations and procedures

20. 20 Joint Commission Focus on activities with high volume, a degree of risk and that tend to produce problems for staff or patients, and/or are costly Need to establish a threshold for evaluation Frequency of data collection and review is based on the significance of the event and the extent to which data reflects improvement Can compare to other organization to improve performance (Benchmarking) http://www.jcaho.org/standards

21. 21 Joint Commission - Standards Patient focused functions –Patient rights and organizational ethics –Assessment of patients –Education –Continuum of care –Linguistically and culturally appropriate care Organizational focused functions Structures with functions

22. 22 Some “Hot” Areas –Joint Commission Environment of care - is space equipped to provide care Patient education activities (food-drug- drug/drug interactions, anticipatory guidance) Medication management to reduce error Patient outcomes- vigorous analysis of practice Documentation in medical record Patient safety (new 7/01 now majority of standards)

23. 23 Joint Commission - Improving Organizational Performance Data are systematically aggregated and analyzed on an ongoing basis Improved performance is achieved and sustained.

24. 24 Joint Commission Beginning January 1, 2006, on-site surveys for accredited ambulatory care organizations and office-based surgery practices will be unannounced. NP and PA credentialing process is becoming increasingly important

25. HEDIS 2009 Weight assessment and counseling for nutrition and physical activity for children Childhood immunization Chlamydia screening Appropriate testing for children with pharyngitis Appropriate treatment for children with upper respiratory infection Follow up care for children prescribed with ADHD medication

26. HEDIS 2009 Children with chronic conditions Children and adolescent access to primary care practitioners Use of appropriate medications for people with asthma Follow up after hospitalization for mental illness Medical assistance with smoking cessation Annual dental visit

27. 27 Chart Reviews How many?- 600 do 5% Need to be done to monitor medical and behavioral health record compliance- NCQA, Joint Commission, Insurance companies Do focused reviews at the same time- CQI Tool or others

28. 28 What else do you need to do? A person on staff is responsible for CQI Monitor the environment of care Written policies and procedures in place Written scope of care Patient satisfaction measured periodically Regular tracking of key variables to monitor operations: no shows, cancellations, new to revisit ratio, apt to walk in ratio.

29. 29 Discussion

30. 30 Selecting a Standard of Care

31. 31 Guidelines for Review US Preventive Services Task Force Bright Futures GAPS American Academy of Family Physicians

32. 32 Standards of Care : Themes Comprehensive Periodic Emphasis on prevention and education Certain conditions/issues appear over and over

33. 33 Considerations In Guideline Selection Age of your patient population Characteristics of your clinical practice Practicality of implementing in your practice Are there tools that can be used effectively? Are there systems in place to document and measure quality?

34. 34 Quality Improvement Initiatives Related To Children And Adolescents

35. 35 An Emerging National Agenda Crossing the Quality Chasm (IOM, 2001) National Health Care Quality Report (IOM, 2001) National Academy of Science call for system of rewards based on performance ( NY Times, October 31 st, 2002)

36. 36 FACCT (The Foundation for Accountability- Closed) Dedicated to helping consumers have information they need to make better decisions about their health care. Formulates measures that consumers find relevant and easy to understand. Child and Adolescent Health Measurement Initiative (CAHMI) - measure development –Young Adult Health Care Survey –Living with Illness –Promoting Healthy Development Measures tested, submitted to HEDIS, used for plan QI, consumer information development, and research studies

37. 37 Child and Adolescent Health Measurement Initiative (CAHMI) - Young Adult Health Care Survey (YAHCS) Measures not just receiving care but the quality of care that adolescents receive for accountability purposes Collaboration between NCQA, AAP, Children Now!,CDC, AHRQ, etc Focus is on preventive care and align with national recommendations Adolescents’ asked directly about the care they received

38. 38 CAHMI - YAHCS Adolescent Preventive Care (14-18 year olds) 56 questions –Health care use –Privacy –Health and safety –Health information –Health care in the last 12 months –Your health –Demographics Reliable and valid http://dch.ohsuhealth.com/index.cfm?pageid=451&sectionID=133&open=148

39. 39 Consumer Assessment of Health Plan Survey (CAHPS) Instrument in development that is intended to capture information about the experience and satisfaction adolescents’ report about basic aspects of care such as access and communication with providers. Shares 20 items with YAHC Parents complete survey first then have adolescents complete https://www.cahps.ahrq.gov/default.asp

40. 40 NICHQ: National Initiative for Child Health Quality An action-oriented organization dedicated solely to improving the quality of health care provided to children. Mission is to eliminate the gap between what is and what can be in health care for all children. http://www.nichq.org

41. 41 NICHQ: National Initiative for Child Health Quality Asthma ADHD Children with special healthcare needs Children in foster care Preventive care Cultural competency Obesity http://www.nichq.org

42. 42 2005 National Health Care Disparities Reports Proportion of children whose parents report getting advice on physical activity is lower among poor and near poor children. Childhood asthma admission rates are highest among black children Many racial and ethnic minorities and persons of lower socioeconomic position are less likely to receive childhood immunizations

43. 43 Issues Influencing Mental Health and CQI Limited evidence base and variations in care especially for children Diversity of providers Characteristics that distinguish mental health from general health care Characteristics of SBHC practice Charting Less well developed infrastructure for quality measurement

44. 44 Organizations And Initiatives Conducting Systematic Evidence Reviews Related To Mental Health Cochrane Group (developmental, psychosocial and learning problems) USPSTF (suicide risk) National Registry of Evidence Based Programs and Practice (brand name programs for prevention, CBT, multisystemic therapy) Agency for Healthcare Research and Quality (AHRQ) - ADHD

45. 45 Organizations and Initiatives Conducting Systematic Evidence Reviews DOJ Federal Collaboration on What Works (prevention, intervention, treatment for juvenile justice, drug and ETOH) Professional Associations

46. 46 How Organizations Respond To Problems And Opportunities To Improve Pathological: hide information, shoot the messenger, cover failures, crush new ideas Bureaucratic: ignore information, tolerates messengers, promotes self as just and merciful, new ideas= problems Generative: information is sought, messengers are trained, failures lead to inquiry, new ideas are welcomed (Westrum,2004)

47. 47 The Learning Organization “…organizations where people continually expand their capacity to create the results they desire, where new and expansive patterns of thinking are nurtured, where collective aspiration is set free, and where people are continually learning to see the whole together.”(Senge,1990)

48. 48 The Learning Organization There is a process of self examination and continuous improvement Openness and collaboration (patient centered care) The best have the capacity to learn, adapt and improve the fastest

49. 49 Patient centered care Openness drives improvement Well being of patients is paramount People should be able to learn anything that affects their lives

50. 50 Why be transparent? Leads to greater improvement Involves parents and users Includes a view of why problems exist that you would not have considered before There is by in from all involved to improve

51. 51 What needs to happen in order to be transparent Commitment to change Creation of a culture of transparency –Leadership –Re train staff –Regular reporting mechanism –Project level data – it is not about the individual –Opportunities to practice being transparent

52. 52 Risks The blame game Fear users will stop using the service Fears regarding loss of position -status, jobs etc

53. 53

54. 54 Recommendations from NASBHC: Share your improvement data Academic Success: with the school Productivity: with stakeholders CQI Tool: with insurers and employers …now with users and families.

55. 55 Learning more about a culture of transparency The Bell Curve, Atul Gawande (2004) http://www.newyorker.com/fact/content/?041206fa_fact http://www.newyorker.com/fact/content/?041206fa_fact When Things Go Wrong (Harvard teaching institutions) http://www.ihi.org/NR/rdonlyres/A4CE6C77-F65C- 4F34-B323- 20AA4E41DC79/0/RespondingAdverseEvents.pdf http://www.ihi.org/NR/rdonlyres/A4CE6C77-F65C- 4F34-B323- 20AA4E41DC79/0/RespondingAdverseEvents.pdf Pursuing Perfection- Cincinnati Children's http://www.cincinnatichildrens.org/about/perfect /

56. 56 The patient has a right to transparency “Nothing about me without me” Caregivers have no moral or legal authority to withhold information Withholding information is arrogant and disrespectful Not knowing causes anger, resentment and loss of trust (Leape, Atlanta, IHI IMPACT Mtg May 2006 )

57. 57 Pay for Performance The goal of pay-for-performance programs should be to align reimbursement with the practice of high quality, safe health care for all consumers. Controversial Complicated Cost reduction vs incentives Becoming more widely implemented. Providers in HMOs being paid based on their performance.

58. 58 Standards of Care for SBHCs Historical –Funders –States NASBHC (Principles, CQI Tool, MHPET, Collaboratives, Productivity)

59. 59 BREAK

60. 60 Best practice in SBHCs: Standards, Principles, Program Evaluation, and Evaluation of Clinical Care

61. 61 Principles for SBHCs Supports the school Responds to the community Focuses on the student Delivers comprehensive care Advances health promotion activities Implements effective systems Provides leadership in adolescent and child health

62. 62 A Program Evaluation Tool for SBHCs The 7 principles and their goals Structures needed to implement the goals - the physical and organizational properties of the environment Processes to support the goals - what is done to achieve the desired outcome Outcomes that can be attributed to a desirable performance - satisfaction, behavior,morbidity

63. 63 Examples of Outcomes Reduced number of students who leave school during the day due to illness High parent satisfaction Increased enrollment for and utilization of SBHC services Patient perception that well-being has improved Increased compliance rates as measured by follow-up visits completed, prescriptions filled, therapy attended, referrals completed etc.

64. 64 Questions Regarding Measurement of Quality in SBHCs Are the things we want to measure truly important to the health of students? Do the measures identify good health and care? Can clinical practice make an impact on these conditions? Are the measures practical? Do they work in the field?

65. 65 Mental Health Planning and Evaluation Template (MHPET) 34 indicator measure which evaluates eight dimensions related to providing mental health services in schools –Operations –Stakeholder involvement –Staff and training –Identification, referral and assessment –Service delivery –School coordination and collaboration –Community coordination and collaboration –Quality assessment and improvement www.nasbhc.org

66. 66 Evaluation of Clinical Services in SBHCs (CQI Tool) Sentinel conditions as a marker of the quality of clinical care The foundation is an annual risk assessment and biennial physical exam Limited number of conditions allows for meaningful evaluation Intent is for the tool to be flexible

67. 67 The SBHC CQI Tool Six conditions per age group (choose one of two mental health conditions) References to support the inclusion of the condition and to use to improve performance Resources necessary to provide quality care relative to that sentinel condition Markers of care for that condition Measurement of the markers on a scale of 1 to 5 with threshold at 3

68. 68 Sentinel Conditions for Elementary School (CQI Tool) Annual risk assessment and physical exam Asthma Risk for Type 2 diabetes Poor School Performance Oral Health Mental health –Depression –Psychological trauma

69. 69 Sentinel Conditions for Middle School and High School (CQI Tool) Annual risk assessment and physical exam Asthma Risk for Type 2 diabetes Tobacco use Substance use Chlamydia screening Immunizations Poor School Performance Oral Health Mental health –Depression –Psychological trauma

70. 70 SBHC CQI Tool The tool Data collection forms Instructions Resources/glossary/directory Guide to sampling populations http://www.nasbhc.org

71. CQI Glossary

72. 72 Why Is Improving Practice a Problem? The demand for services keeps you reacting to crises and acute care requests Lack of administrative support (school and SBHC operations/budget) Effect on productivity

73. 73 Why Is Improving Practice a Problem? Reimbursement Lack of parental involvement Forces the providers to address the “hard” issues SBHC needs the partnerships/referral relationships to support providing preventative services

74. 74 Why Does It Matter? Consistent with a standard of care Realizes the potential of the SBHC model Valued by insurers, government, parents, the community and students themselves (?) Focused on finding adolescents at risk or already in trouble Staff satisfaction

75. 75 Essential Elements for Successful Prevention in SBHCs (NASBHC) A prevention mission A supportive environment for students A competent staff Collaborative partnerships for prevention Effective strategies Accountability

76. 76 Factors Associated with Successful Adoption of Innovations: Organizational Adopters Decentralized decision making Can identify, capture, share and integrate new knowledge Receptive to change through strong leadership, clear vision, good management and climate conducive to experimentation and risk taking Effective data systems Ready for change Greenhalgh et al 2004

77. 77 NASBHCs Benchmarking Efforts Compare yourself to other apples not oranges Document the SBHC experience for improvement and advocacy Tools –CQI ( revision in 2008) –Productivity ( on web www.nasbhc.org)www.nasbhc.org –Cost ( in development, contact lbrey@nasbhc.org if interested in participating in beta test) –MH PET ( on web www.nasbhc.org)www.nasbhc.org