Performance Improvement in
Community Health Centers
Sponsored by the
National Association of Community Health Centers
Presented By Shoreline Health Solutions, LLC
Trudy Brown Ripin, MPH
Molly K. Gwisc, MPH
President & Founder
Presentation Goals
 Understand Performance Improvement methodology, as well as
practical techniques for quality improvement.
 Effectively use the PI model in a new start Community Health
 Review case studies to demonstrate PI in real scenarios
 Understand proactive and reactive performance improvement
Improving Performance
How do we know we are providing high quality care
and services?
Do we set and achieve appropriate and realistic
How do we measure improvement?
What is Performance Improvement?
 Performance Improvement (PI) is a continuous,
systematic process for improving the agency’s care,
service and operations.
Why do Performance Improvement?
 Methodological way to ensure high quality care & patient safety
 Tells you if changes worked
 PI model gives you concrete steps to simplify a complex process
 BPHC and JCAHO require it
What If We Don’t Measure?
 You won’t know if the change WORKED
 You won’t know WHICH PART of the change worked
 You could make things WORSE
 Others may NOT BELIEVE the change worked
Selecting a PI Project
 Triggered by a specific incident
 Based on existing data trends
 Prioritizing: High Risk, High Volume, Problem Prone
 Directly impacts patient care or patient satisfaction
Key Elements of a PI Model
Establish baseline
2. Set benchmark
3. Make change
4. Measure your change
5. Follow-up
 PDSA is one of many models for PI
 Four - step cycle to plan and measure change
 FOCUS component maps out Pre-Work to PDSA
Find a process to improve
Organize a team
Clarify what is currently happening (baseline data)
Understand where and why problems occur
Select the process improvement and benchmark
Plan the Performance Improvement strategy
Do a trial run, collect data as you go
Study your results
Was there a measurable improvement?
If not, go back to PLAN until benchmark is achieved
Act! Ongoing monitoring for sustained improvement
Operational PI Examples
 Patient Wait Time
 Patient Satisfaction
 Staff Satisfaction
 Claims Denial
 Collections
Operational PI Case Study
Improving Patient Wait Times
F Chose wait times in response to patient demand - patient complaints
O Formulated team involved in areas of wait time – included a clinical
provider, medical assistant, registration staff, billing staff, senior
Collected baseline data through wait time study
Understood problem areas by clarifying where delays occur - delays
occurred at registration, waiting in exam room, and billing
Selected to de-centralize intake as first process improvement –
benchmark is reducing wait time by 20 minutes.
Operational PI Case Study
Improving Patient Wait Times
P Plan thoroughly developed and outlined by team
D Plan implemented in pediatrics
S Data collected and not at benchmark – repeat cycle
A Benchmark achieved!! Implemented changes in all
High Level Integration
 An effective PI program incorporates all data
sources through a central PI Committee and
integrated PI Program infrastructure.
PI Committee Structure
 Select Representative Members
 Integrate into all sites
 Meet regularly
 Appoint PI Coordinator
 Complete assignments between meetings
 Select 1-2 PI Priorities Annually
 Appoint PI Teams
 Ensure Ongoing Monitoring
 Review Key Data Trends From All Sources
Components of PI Program
Proactive Strategies
Peer Review
Chart Completeness Review
Informed Consent – High Risk Procedures
Patient Satisfaction
Reactive Strategies
Incident Tracking
Patient Complaint Tracking
Sentinel Event Response
Peer Review
• Providers Review Each Other’s Charts
• Standardized Audit Tool
• Identify Trends
• Report Results to Staff and Leadership
Peer Review Goals
 Review Individual Trends Over Time
 Review Clinical Practice Trends
 Answer Specific Clinical Questions
Chart Completeness Review
 Evaluates Medical Record Documentation
 Checklist is Standardized
 Usually Done Monthly
 Can Be Done By Non-Clinical Staff
High Risk Procedures – Informed Consent
• What is a High-risk Procedure?
 Risk Of Serious Complications
 Examples Include Perforation & Infection
• Informed Consent Needed
 Understand Benefits & Risks
 Be Informed Of Alternatives
 Good Clinical Care
 Liability Protection/ Risk Management
Patient Satisfaction Program
 Components of a Comprehensive Pt Satisfaction
 Surveys
 Staff Training
 Patient Suggestion/Comment Box
 Patient Complaint Tracking System
Incident Tracking
 Documenting the Event
 Incident Review
 Resolving the Incident
 Identifying Trends
Patient Complaint Tracking
• Identifies customer service and communication problems
• Utilizes same process as Incident Tracking
 Rapid response to each complaint
 Feedback to patient describing agency response
 Complaint patterns indicate systemic problems
 Structured response to systems problems
Sentinel Event Response
 What is a sentinel event?
 Near Miss
 Do Not Wait for a Trend
 Root Cause Analysis
Clinical PI Examples
 Triage:
 Child with 104 degree fever scheduled for next day
 Walk-in patient left waiting for 2 hours when should have
been sent to ER
 Evaluation
 Missed Diagnosis
 Mis-Diagnosis
 Labs not ordered
 Treatment
 Wrong medication prescribed
 Perforation during IUD insertion
Clinical PI Examples
 Lab Issues
 Patient given wrong person’s test results
 Lab tests ordered, but never done
 Results never come back from outside lab
 Controlled Substances
 Stolen prescription pads / forged prescriptions
 Patient seeing multiple providers / pharmacies to obtain
controlled substances
Clinical PI Examples
 Chart Documentation
 Illegible handwriting
 Provider seeing patient without chart
 Phone/ Communication
 Provider never receives patient message
 Language and cultural barriers
Clinical PI Case Study
Follow-Up for Abnormal Labs
F Identified problem through incident tracking.
O Team included Medical Director, Nurse Coordinator, Medical
Assistant, Lab Tech, staff person receiving mail / fax / delivery of lab
C Baseline data collected via lab testing log, 3 week period reviewed.
U Problem areas included use of multiple outside labs, high volume,
part-time clinicians, no clear person in charge of process.
S Identified responsible person to track all abnormal labs. Benchmark
set at 100% follow-up rate within 24 hours of notification.
Clinical PI Case Study
Follow-Up for Abnormal Labs
P Plan thoroughly developed and outlined by team.
D Implemented for three providers
S Data collected: 24-hour follow-up achieved for 95% of
cases. Not at benchmark – repeat cycle.
A Benchmark achieved!! Implemented changes for all
 Institute for Healthcare Improvement
 Your State’s Primary Care Association/Organization
 Contact us with questions
(Trudy or Molly, Shoreline Health Solutions) or (860) 395-5630

Performance Improvement for Community Health Centers